PATH TO HEALTH DRUG FORMULARY

Administered by MedImpact February 2019 INTRODUCTION

Foreword

The below table describes Path to Health prescription coverage:

Patient out-of-pocket cost  $5 copayment per prescription  No monthly share of cost requirement Benefit maximums  $500 per prescription claim  $1500 maximum benefit per Path to Health enrollment period Drug exclusions  Specialty drugs and contraceptives are excluded

This document represents the efforts of MedImpact and Path to Health to provide physicians and pharmacists with a method to evaluate the various drug products available under the Path to Health Benefit. The medical treatment of patients is frequently related to the practical application of drug therapy. Due to the vast availability of medication treatment modalities, a reasonable program of drug product selection and drug usage must be developed. The goal of the Path to Health Formulary is to enhance the ability of physicians and pharmacists participating in Path to Health to provide optimal cost effective drug therapy for Path to Health members.

The development, maintenance, and improvement of the Path to Health Formulary are evolutionary and require on-going oversight. This is accomplished by a pharmacy and therapeutics review process conducted by a panel of physicians and pharmacists. The Path to Health Formulary is a continuously reviewed and revised list of drug products that reflects the consensus clinical opinion of the panel. Using this Formulary, you are encouraged to review the information and provide input and comments to Path to Health.

Path to Health uses the following criteria in the evaluation of product selection for the Path to Health Formulary: . The drug product must demonstrate unequivocal safety for medical use. . The drug product must be efficacious and be medically necessary for the treatment, maintenance or prophylaxis of the medical condition. . The drug product must demonstrate therapeutic marker outcomes accepted by the medical community. . The drug product must be accepted for use by the medical community. . The drug product should have a favorable cost ratio for the treatment of the medical condition.

How to Use the Drug Formulary

The Path to Health Formulary is a list of covered and preferred drug agents for Path to Health members. All products are listed by their generic names and most common proprietary (branded) name. The Path to Health Formulary may be accessed by using the index, both by generic and proprietary name (in small capital letters) and by therapeutic drug category. Any product not found in this Formulary listing shall be considered a Non-Formulary Drug.

1 Coverage Limitations

The Path to Health Formulary does not provide information regarding the specific coverage or limitations an individual member may have. Path to Health members may have specific limitations which are not reflected in this Drug Formulary. This Drug Formulary contains only FDA-approved outpatient drugs for eligible members and does not apply to non-FDA approved drugs or medications used in in-patient settings. If a Path to Health member has any specific questions regarding coverage, they should contact Path to Health at (916) 649-2631 for further explanation of benefits.

Path to Health members are not eligible to receive prescription drug services outside of California and the designated border state areas of Oregon, Nevada and Arizona.

Generic Substitution

When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name indicated. The brand names listed are for reference use only and do not denote coverage, unless specifically noted. Greater economy is realized through the use of generic equivalents. This policy is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become available generically are subject to review by the Path to Health pharmacy and therapeutics review process.

Path to Health approves such multisource drugs for addition to the maximum allowable cost (MAC) list based on the following criteria:

 A minimum of one “A” rated source of the product.  An FDA Rating for generic equivalency.  Review by Path to Health for efficacy and safety.  Certain drug products with complex pharmacokinetics, dosage forms, narrow therapeutic efficacy or where blood level maintenance is crucial will not be subject to substitution. These products are:

 Coumadin  Dilantin  Lanoxin  Premarin  Synthroid

This list is reviewed and updated periodically based on the clinical literature and available pharmacokinetic principals of the drug products. If a physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the medication request process.

Experimental Drugs

The experimental nature or use of drug products will be determined by Path to Health using current medical literature. Any drug product or use of an existing product that is determined to be experimental will be excluded from coverage.

Prior Authorization

Drug products that are listed as Prior Authorization (PA) required require approval when the member presents a prescription to a network pharmacy. To obtain coverage, the prescribing physician may:

A. Fax a completed Medication Request Form (MRF) to MedImpact at (858) 790-7100, or

2 B. Contact MedImpact at (800) 788-2949 and provide all necessary information requested.

If the request does not meet the criteria established by Path to Health, the request will be denied and alternative therapy may be recommended. Each request will be reviewed on individual patient need and approval may be given if a documented medical need exists.

Request Process for Non-Formulary Agents

Coverage for non-formulary agents may be requested in advance by physicians. When a Path to Health member gives a prescription order for a non-formulary drug to a pharmacist, the pharmacist should notify the physician and member of the nonformulary status. The physician, pharmacist or member may then call MedImpact at (800) 788-2949 to initiate the medical exception process. To obtain coverage, the prescribing physician may:

A. Fax a completed Medication Request Form (MRF) to MedImpact at (858) 790-7100, or

B. Contact MedImpact at (800) 788-2949 and provide all necessary information requested.

The following general criteria are used for approval. 1) The use of Path to Health Formulary Drug Products is contraindicated in the patient. 2) The patient has failed an appropriate trial of Formulary or related agents. 3) The choices available in the Path to Health Formulary are not suited for the present patient care need and the drug selected is required for patient safety. 4) The use of a Path to Health Formulary Drug may provoke an underlying condition, which would be detrimental to patient care.

Path to Health recognizes that not all medical needs can be met with agents listed in this document and encourages inquires about optional therapies.

Step Care Agents

Drug products defined as step care will undergo an electronic pre-authorization process per Path to Health guidelines, which requires a trial of first-line drug(s) before a Step Care drug will be covered at the formulary brand level. If recommended guidelines for first-line therapy are not met, then the Step Care drug may be subject to review through the prior authorization process.

Quantity Limits

Limitations on quantity may be placed on certain products due to safety, therapeutic or cost-effectiveness considerations. Prescriptions for such agents exceeding the quantity limit (QL) will be subject to the prior authorization process.

Appeals Process

Prior authorization and medical exception requests are evaluated based on medical necessity and safety as described. In the event of denial, providers or Path to Health members may request a formal appeal verbally or in writing within sixty (60) days of denial notification. To request an appeal, call (800) 788-2949 or send your written appeal request to the following address:

3 MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court, San Diego, CA 92131 Attention: Appeals Coordinator or Fax (858) 790-6060

4 Formulary Process and Communication

The Path to Health Formulary is a tool to promote cost-effective prescription drug use. While every attempt has been made to create a document that meets all therapeutic needs, the art of medicine makes this a formidable task. Path to Health welcomes input on the formulary from physicians and pharmacists providing services to Path to Health clients. Suggestions and comments should be submitted to the Path to Health at the following address:

Path to Health ATTN: Pharmacy and Therapeutics Panel 1545 River Park Drive, Suite 435 Sacramento, CA 95815 (916) 649-2631

5 TABLE OF CONTENTS FOREWORD ...... 1 HOW TO USE THE DRUG FORMULARY ...... 1 COVERAGE LIMITATIONS ...... 2 GENERIC SUBSTITUTION ...... 2 EXPERIMENTAL DRUGS ...... 2 PRIOR AUTHORIZATION ...... 2 REQUEST PROCESS FOR NON-FORMULARY AGENTS ...... 3 STEP CARE AGENTS ...... 3 QUANTITY LIMITS ...... 3 APPEALS PROCESS ...... 3 FORMULARY PROCESS AND COMMUNICATION ...... 5 CENTRAL NERVOUS SYSTEM AGENTS ...... 10 ANALGESIC AND ANTI-INFLAMMATORY AGENTS ...... 10 Non-Steroidal Anti-Inflammatory Agents ...... 10 Miscellaneous Arthritis Agents ...... 10 Migraine Agents ...... 10 Opiate Agonists ...... 10 Narcotic Withdrawal Therapy Agents ...... 11 Opiate Antagonists ...... 11 Miscellaneous Analgesics ...... 11 Miscellaneous Central Nervous System Agents ...... 11 ANTICONVULSANT AGENTS ...... 11 Barbiturate Anticonvulsants ...... 11 Benzodiazepine Anticonvulsants ...... 11 Hydantoin Anticonvulsants ...... 11 Miscellaneous Anticonvulsants ...... 11 ANTIPARKINSONIAN AGENTS ...... 12 MUSCLE RELAXANT AGENTS ...... 12 Skeletal Muscle Relaxants ...... 12 PSYCHOTHERAPEUTIC AGENTS ...... 12 Tricyclic Antidepressant Agents ...... 12 S.S.R.I. Agents ...... 12 S.N.R.I. Agents ...... 12 M.A.O. Inhibitor Agents ...... 12 Miscellaneous Antidepressant Agents ...... 12 Antimanic Agents ...... 13 Benzodiazepines ...... 13 Antipsychotic Agents ...... 13 Antipsychotic/SSRI Combination Agents ...... 13 Miscellaneous Anxiolytics, Sedatives, and Hypnotics ...... 13 CARDIOVASCULAR/BLOOD AGENTS ...... 14 ANTIARRHYTHMIC AGENTS ...... 14 Antidysrhythmic Drug Agents ...... 14 ANTIHYPERTENSIVE AGENTS ...... 14 Alpha-Adrenergic Antagonist Antihypertensive Agents ...... 14 Beta-Adrenergic Antagonist Agents ...... 14 Combination Alpha-Beta Antagonist Agents...... 14 Angiotensin Converting Enzyme Inhibitor Agents ...... 14 Angiotensin Receptor Blocker Agents ...... 14 Calcium Channel Blocking Agents...... 15 Centrally Acting Antihypertensive Agents...... 15 Combination Antihypertensive Agents ...... 15 Drugs for Pheochromocytoma ...... 15 Potassium-Sparing Diuretics ...... 15 Loop Diuretics ...... 15 Thiazide and Related Diuretics ...... 15 Vasodilator Antihypertensive Agents ...... 15

6 ANTILIPEMIC AGENTS ...... 16 BLOOD AGENTS ...... 16 Coagulants and Anticoagulants ...... 16 HEMORHEOLOGIC AGENTS ...... 16 CARDIAC GLYCOSIDE AGENTS ...... 16 ANTIPLATELET AGENTS ...... 16 VASODILATING AGENTS ...... 16 GASTROINTESTINAL AGENTS ...... 16 ANTIDIARRHEAL AGENTS ...... 16 ANTIEMETIC AGENTS ...... 17 ANTIMUSCARINIC/ANTISPASMODIC AGENTS ...... 17 ANTIULCER/ANTIPEPTIC AGENTS ...... 17 BOWEL EVACUANT AGENTS ...... 17 DIGESTIVE ENZYMES ...... 17 GALLSTONE SOLUBILIZING AGENTS ...... 18 GASTROINTESTINAL STIMULANT AGENTS ...... 18 H2 ANTAGONIST AGENTS ...... 18 LAXATIVE AGENTS ...... 18 MISCELLANEOUS GASTROINTESTINAL SUPPLIES ...... 18 MISCELLANEOUS GASTROINTESTINAL AGENTS ...... 18 ANTI-INFECTIVE AGENTS ...... 18 AMEBICIDES ...... 18 ANTIHELMINTIC AGENTS ...... 18 ANTIBIOTIC AGENTS ...... 18 Aminoglycosides ...... 18 Cephalosporins ...... 18 Macrolide Antibiotic Agents ...... 19 Miscellaneous Antibiotic Agents ...... 19 Penicillins ...... 19 Quinolones ...... 19 Sulfonamide Agents ...... 19 Tetracyclines ...... 19 ANTIFUNGAL AGENTS ...... 19 ANTIMALARIAL AGENTS ...... 20 ANTITUBERCULOSIS AGENTS ...... 20 ANTI-ULCER ERADICATION AGENTS ...... 20 OTHER ANTIVIRAL AGENTS...... 20 LEPROSTATIC AGENTS ...... 20 RESPIRATORY/EENT AGENTS...... 20 ANTIHISTAMINE AGENTS ...... 20 Single Entity Alkylamine Agents ...... 20 Single Entity Ethanolamine Agents ...... 20 Non-Sedating Single Entity Agents ...... 20 Miscellaneous Antihistamine Agents...... 21 ANTIHISTAMINE/DECONGESTANT COMBINATION AGENTS ...... 21 Antihistamine/Decongestant Agents...... 21 ANTITUSSIVE AGENTS ...... 21 Non-Narcotic Antitussive Agents ...... 21 Narcotic Antitussive Agents ...... 21 Decongestants ...... 21 ASTHMA/COPD AGENTS ...... 21 Inhaled Sympathomimetic (Adrenergic) Agents ...... 21 Oral Sympathomimetic (Adrenergic) Agents ...... 21 Inhaled Oral Corticosteroid Agents ...... 22 Leukotriene Receptor Antagonists ...... 22 Respiratory Smooth Muscle Relaxant Agents ...... 22 EXPECTORANT AGENTS ...... 22 MUCOLYTIC AGENTS ...... 22 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS ...... 22

7 Ophthalmic Antibiotic Agents ...... 22 Ophthalmic Anti-Inflammatory Agents, Corticosteroid ...... 22 Ophthalmic Anti-Inflammatory Agents, NSAIDs ...... 22 Ophthalmic Antiviral Agents ...... 22 Ophthalmic Beta Blockers ...... 22 Ophthalmic Miotic Agents ...... 23 Ophthalmic Mydriatic Agents ...... 23 Ophthalmic Sulfonamide Agents ...... 23 Miscellaneous Ophthalmic Agents ...... 23 Otic Anti-Infective Agents ...... 23 Miscellaneous Otic Agents ...... 23 INHALED/ORAL EENT AGENTS ...... 23 Inhaled Nasal Agents ...... 23 Carbonic Anhydrase Inhibitor Agents ...... 23 Local Anesthetic Agents ...... 23 MISCELLANEOUS EENT AGENTS ...... 23 DIABETES AND THYROID AGENTS ...... 24 ORAL DIABETES AGENTS ...... 24 Sulfonylureas ...... 24 Non-Sulfonylureas...... 24 Combination Diabetes Agents ...... 24 INSULIN AGENTS ...... 24 MISCELLANEOUS DIABETES AGENTS ...... 24 THYROID AGENTS ...... 24 Antithyroid Agents ...... 25 HORMONE AGENTS ...... 25 ORAL ADRENAL CORTICOSTEROID AGENTS ...... 25 ANDROGEN AGENTS ...... 25 BONE RESORPTION INHIBITORS ...... 25 PARATHYROID HORMONE ...... 25 ESTROGEN AGENTS ...... 25 Estrogen Agonist-Antagonists ...... 26 CONTRACEPTIVES ...... 26 OXYTOCIC AGENTS ...... 26 PITUITARY AGENTS ...... 26 PROGESTIN AGENTS ...... 26 GENITOURINARY AGENTS ...... 26 URINARY ANTI-INFECTIVE AGENTS ...... 26 URINARY ANTI-SPASMODIC AGENTS ...... 26 GENITOURINARY SMOOTH MUSCLE RELAXANT AGENTS ...... 26 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ...... 26 TOPICAL/MUCOUS MEMBRANE AGENTS ...... 27 KERATOLYTIC AGENTS ...... 27 MISCELLANEOUS SKIN/MUCOUS MEMBRANE AGENTS ...... 27 TOPICAL ANTIBIOTIC AGENTS ...... 27 TOPICAL ANTIFUNGAL AGENTS ...... 27 VAGINAL ANTIFUNGAL AGENTS ...... 27 VAGINAL ANTI-INFECTIVE AGENTS ...... 28 TOPICAL ANTI-INFLAMMATORY AGENTS ...... 28 TOPICAL ANTIPRURITIC AND LOCAL ANESTHETIC AGENTS ...... 28 TOPICAL ANTIVIRAL AGENTS ...... 28 TOPICAL MISCELLANEOUS ANTI-INFECTIVE AGENTS ...... 28 SCABICIDE/PEDICULICIDE AGENTS ...... 29 MISCELLANEOUS/UNCLASSIFIED AGENTS ...... 29 ELECTROLYTE AGENTS ...... 29 Miscellaneous Agents ...... 29 Potassium Agents ...... 29 HEAVY METAL ANTAGONIST AGENTS ...... 30 VITAMIN AGENTS ...... 30

8 Vitamin B-Complex Agents ...... 30 Vitamin D ...... 30 Vitamin K Activity Agents ...... 30 Iron Agents ...... 30 DIAGNOSTIC TESTING ...... 30 Blood Glucose Supplies ...... 30 ALCOHOL AND SMOKING DETERRENT AGENTS ...... 30 GOUT AGENTS ...... 30 OTHER MEDICAL SUPPLIES ...... 31

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CENTRAL NERVOUS SYSTEM AGENTS

Analgesic and Anti-Inflammatory Agents Non-Steroidal Anti-Inflammatory Agents FIRST LINE AGENTS Aspirin ASPIRIN Aspirin EC ECOTRIN Celecoxib CELEBREX Diclofenac Sodium VOLTAREN Etodolac LODINE Ibuprofen MOTRIN (INCLUDES OTC) Indomethacin INDOCIN Ketoprofen ORUVAIL, 200MG STRENGTH NON-FORMULARY Indomethacin, Sustained Release INDOCIN SR Meloxicam Tablets MOBIC (TABLETS ONLY), SUSPENSION NON-FORMULARY Nabumetone RELAFEN

Naproxen NAPROSYN Naproxen Sodium ANAPROX ANAPROX DS Salsalate DISALCID Sulindac CLINORIL Piroxicam FELDENE SECOND LINE AGENTS SE Etodolac Extended Release LODINE XL, STEP THERAPY, RESTRICTED TO A TRIAL OF 2 UNRESTRICTED NSAIDS IN THE PAST 90 DAYS Miscellaneous Arthritis Agents Leflunomide ARAVA Migraine Agents APAP/Dichloralphenazone/Isomethep MIDRIN Butalbital/APAP/Caffeine ESGIC ESGIC PLUS FIORICET Butalbital/Aspirin/Caffeine (Tablets Only) FIORINAL Ergotamine/Caffeine CAFERGOT QL Naratriptan AMERGE, LIMITED TO 9 TABLETS/MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH QL Rizatriptan MAXALT, MAXALT MLT, LIMITED TO 9 TABLETS/MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH QL Sumatriptan IMITREX, LIMITED TO 4 INJECTIONS, 9 TABLETS, OR 6 NASAL UNITS PER MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH, SUMAVEL NON-FORMULARY SE, QL Eletriptan RELPAX, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF SUMATRIPTAN IN THE PAST 120 DAYS, LIMITED TO 9 TABLETS/MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH SE, QL Zolmitriptan ZOMIG, ZOMIG ZMT STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF SUMATRIPTAN IN THE PAST 120 DAYS, LIMITED TO 9 TABLETS OR 6 NASAL UNITS PER MONTH, ONLY 1 RX FOR ANY TRIPTAN/MONTH PA, QL Dihydroergotamine MIGRANAL, PA REQ, LIMITED TO 1 KIT (4 TREATMENTS) PER MONTH Opiate Agonists

10 QL Acetaminophen/Codeine TYLENOL #2, #3, #4, LIMITED TO #240/MONTH OR 960ML/MONTH ; ORAL SUSPENSION AND VOPAC NON- FORMULARY QL Acetaminophen/Hydrocodone NORCO 5/325, LIMITED TO #240/MONTH QL NORCO 7.5/325, LIMITED TO #180/MONTH QL NORCO 10/325, LIMITED TO #150/MONTH ALL OTHER HYDROCODONE/APAP STRENGTHS NON-FORMULARY QL Butalbital/APAP/Caffeine/Codeine FIORICET/CODEINE, LIMITED TO #180/MONTH QL Butalbital/Aspirin/Caffeine/Codeine FIORINAL/CODEINE, LIMITED TO #180/MONTH QL Codeine/Aspirin EMPIRIN #2, #3, #4, LIMITED TO #240/MONTH QL Hydromorphone DILAUDID, LIMITED TO #240/MONTH OR 960ML/MONTH QL Morphine MSIR, LIMITED TO #240/MONTH OR 960ML/MONTH QL Morphine SR MS CONTIN/ORAMORPH SR, LIMITED TO #120/MONTH QL Oxycodone OXYIR, LIMITED TO #240/MONTH QL Oxycodone OXYFAST, LIMITED TO #960ML/MONTH QL Oxycodone/Acetaminophen PERCOCET, LIMITED TO #240/MONTH; MAGNACET AND PRIMALEV NON-FORMULARY QL TYLOX, LIMITED TO #240/MONTH QL Oxycodone/Aspirin PERCODAN, LIMITED TO #240/MONTH PA, QL Oxycodone OXYCONTIN, PA REQ, LIMITED TO #60/MONTH Narcotic Withdrawal Therapy Agents Naloxone Spray and Syringes NARCAN; EVZIO NON-FORMULARY Opiate Antagonists Naltrexone REVIA Miscellaneous Analgesics Acetaminophen TYLENOL Tramadol ULTRAM ; ULTRAM ER NON-FORMULARY PA, QL Butorphanol NS STADOL NS, PA REQ, LIMITED TO 2 BOTTLES/MONTH Miscellaneous Central Nervous System Agents Donepezil ARICEPT

Anticonvulsant Agents Barbiturate Anticonvulsants Mephobarbital MEBARAL Phenobarbital PHENOBARBITAL Primidone MYSOLINE Benzodiazepine Anticonvulsants QL Clonazepam KLONOPIN, LIMITED TO #90/MONTH; RAPDIS TABLETS NON- FORMULARY Hydantoin Anticonvulsants Phenytoin DILANTIN, PHENYTEK Miscellaneous Anticonvulsants Carbamazepine TEGRETOL; EQUETRO NON-FORMULARY Carbamazepine Extended Release TEGRETOL XR

Divalproex Sodium DEPAKOTE Divalproex Sodium Extended Release DEPAKOTE ER Gabapentin NEURONTIN Levetiracetam KEPPRA Oxcarbazepine TRILEPTAL Tiagabine GABITRIL Valproic Acid DEPAKENE Zonisamide ZONEGRAN QL Lamotrigine LAMICTAL, LIMITED TO #60/MONTH FOR 100MG AND 150MG, #180/MONTH FOR 25MG

11 QL Topiramate TOPAMAX, LIMITED TO #90/MONTH FOR 25MG, 50MG AND 100MG STRENGTHS Antiparkinsonian Agents Amantadine SYMMETREL Benztropine Mesylate COGENTIN Bromocriptine PARLODEL

Carbidopa/Levodopa SINEMET; PARCOPA NON-FORMULARY Carbidopa/Levodopa CR SINEMET CR Pramipexole MIRAPEX Ropinirole REQUIP; REQUIP XL NON-FORMULARY Selegiline SELEGILINE, ZELAPAR AND EMSAM NON-FORMULARY Trihexyphenidyl ARTANE Muscle Relaxant Agents Skeletal Muscle Relaxants Baclofen LIORESAL QL Carisoprodol SOMA, LIMITED TO #120/MONTH; 250 STRENGTH NON- FORMULARY Chlorzoxazone PARAFON DSC Cyclobenzaprine FLEXERIL Dantrolene Sodium DANTRIUM Methocarbamol ROBAXIN Orphenadrine Citrate NORFLEX Orphenadrine/Aspirin/Caffeine NORGESIC

Psychotherapeutic Agents Tricyclic Antidepressant Agents Amitriptyline ELAVIL Amoxapine ASENDIN Desipramine NORPRAMIN Doxepin SINEQUAN Imipramine TOFRANIL, TOFRANIL PM NON-FORMULARY Maprotiline LUDIOMIL Nortriptyline PAMELOR Protriptyline VIVACTIL S.S.R.I. Agents Citalopram CELEXA Fluoxetine Capsules PROZAC CAPSULES (10MG, 20MG ONLY), TABLETS NON- FORMULARY Fluvoxamine LUVOX Paroxetine PAXIL Sertraline ZOLOFT S.N.R.I. Agents QL Duloxetine CYMBALTA , LIMITED TO #60/MONTH QL Venlafaxine EFFEXOR, LIMITED TO #60/MONTH IF DOSE ≤ 200MG/DAY, LIMITED TO #90/MONTH OF DOSE > 200MG/DAY QL Venlafaxine Extended Release EFFEXOR XR, LIMITED TO #30/MONTH VENLAFAXINE EXTENDED RELEASE TABLETS NON-FORMULARY M.A.O. Inhibitor Agents Phenelzine NARDIL Tranylcypromine PARNATE Miscellaneous Antidepressant Agents

12 Bupropion WELLBUTRIN, APLENZIN NON-FORMULARY Bupropion SR WELLBUTRIN SR, APLENZIN NON-FORMULARY Bupropion XL WELLBUTRIN XL, APLENZIN NON-FORMULARY Clomipramine ANAFRANIL Mirtazapine REMERON TAB, SOLTABS AND 7.5MG TABLETS NON- FORMULARY Trazodone DESYREL MD, QL Nefazodone SERZONE, RESTRICTED TO PSYCHIATRY, LIMITED TO #60/MONTH

Antimanic Agents Lithium Carbonate ESKALITH LITHOBID Benzodiazepines QL Alprazolam XANAX, LIMITED TO #90/MONTH; XANAX XR, NIRAVAM, AND ALPRAZOLAM INTENSOL NON-FORMULARY QL Clorazepate TRANXENE, LIMITED TO #90/MONTH QL Chlordiazepoxide LIBRIUM, LIMITED TO #90/MONTH QL Diazepam VALIUM, LIMITED TO #90/MONTH, DIASTAT NON-FORMULARY QL Flurazepam DALMANE, LIMITED TO #30/MONTH QL Lorazepam ATIVAN, LIMITED TO #90/MONTH; LORAZEPAM ORAL CONCENTRATE NON-FORMULARY QL Temazepam RESTORIL, LIMITED TO #30/MONTH; 22.5MG STRENGTH NON- FORMULARY QL Triazolam HALCION, LIMITED TO #30/MONTH Antipsychotic Agents QL Asenapine SAPHRIS, LIMITED TO #60 PER MONTH QL Aripiprazole ABILIFY, LIMITED TO #30 PER MONTH DISCMELTS NON- FORMULARY Chlorpromazine THORAZINE Clozapine CLOZARIL Fluphenazine PROLIXIN Haloperidol HALDOL, HALDOL DECANOATE-VIALS ONLY Loxapine LOXITANE Molindone MOBAN QL Olanzapine ZYPREXA, LIMITED TO #60/MONTH QL ZYPREXA ZYDIS, LIMITED TO #60/MONTH ZYPREXA INJECTION ZYPREXA RELPREVV

Perphenazine TRILAFON Pimozide ORAP QL Quetiapine SEROQUEL, LIMITED TO #90/MONTH, 25MG STRENGTH NON- FORMULARY. 25MG STRENGTH NOT COVERED FOR INSOMNIA, SUBMIT PA FOR OTHER INDICATIONS. QL Risperidone RISPERDAL, LIMITED TO #60/MONTH Thioridazine MELLARIL Thiothixene NAVANE Trifluoperazine STELAZINE QL Ziprasidone GEODON, LIMITED TO #60/MONTH Antipsychotic/SSRI Combination Agents QL Olanzapine/Fluoxetine HCl SYMBYAX, LIMITED TO #30/MONTH Miscellaneous Anxiolytics, Sedatives, and Hypnotics Buspirone BUSPAR 7.5MG STRENGTH NON-FORMULARY Chloral Hydrate NOCTEC Hydroxyzine ATARAX

13 Hydroxyzine Pamoate VISTARIL Promethazine PHENERGAN QL Zolpidem AMBIEN, LIMITED TO #14/MONTH, AMBIEN CR AND EDLUAR NON-FORMULARY CARDIOVASCULAR/BLOOD AGENTS Antiarrhythmic Agents Antidysrhythmic Drug Agents Amiodarone CORDARONE; 100MG STRENGTH NON-FORMULARY Disopyramide NORPACE Disopyramide CR NORPACE CR Flecainide TAMBOCOR Mexiletine MEXITIL Procainamide PRONESTYL Procainamide SR PROCAN SR PROCANBID Propafenone RYTHMOL Quinidine Gluconate QUINAGLUTE Quinidine Polygalacturonate CARDIOQUIN Quinidine Sulfate CIN-QUIN Quinidine Sulfate SR QUINIDEX Sotalol BETAPACE Antihypertensive Agents Alpha-Adrenergic Antagonist Antihypertensive Agents Reserpine SERPASIL Beta-Adrenergic Antagonist Agents Atenolol TENORMIN Metoprolol Succinate TOPROL XL Metoprolol Tartrate LOPRESSOR Nadolol CORGARD Pindolol VISKEN Propranolol INDERAL Propranolol LA INDERAL LA Combination Alpha-Beta Antagonist Agents Carvedilol COREG; COREG CR NON-FORMULARY Labetalol NORMODYNE TRANDATE Angiotensin Converting Enzyme Inhibitor Agents Benazepril LOTENSIN Captopril CAPOTEN Enalapril VASOTEC Lisinopril PRINIVIL ZESTRIL Angiotensin Receptor Blocker Agents Irbesartan AVAPRO Losartan COZAAR Telmisartan MICARDIS SE, QL Olmesartan BENICAR, STEP THERAPY, LIMITED TO #30/MONTH, RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR LOSARTAN/HCTZ IN THE PAST 90 DAYS SE, QL Valsartan DIOVAN, STEP THERAPY, LIMITED TO #60/MONTH, RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR LOSARTAN/HCTZ IN THE PAST 90 DAYS

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Calcium Channel Blocking Agents Amlodipine NORVASC, LIMITED TO #30/MONTH Diltiazem CARDIZEM Diltiazem SR CARDIZEM SR; CARDIZEM LA NON-FORMULARY Diltiazem CD CARTIA XT Felodipine PLENDIL, LIMITED TO #30/MONTH Nifedipine, Sustained Release ADALAT CC Verapamil CALAN Verapamil LA Tablets CALAN SR; COVERA-HS NON-FORMULARY Verapamil SR Capsules VERELAN Centrally Acting Antihypertensive Agents Clonidine CATAPRES Guanfacine TENEX Methyldopa ALDOMET Combination Antihypertensive Agents Atenolol/Chlorthalidone TENORETIC Benazepril/HCTZ LOTENSIN HCT Bisoprolol/HCTZ ZIAC Captopril/HCTZ CAPOZIDE Enalapril/HCTZ VASORETIC Lisinopril/HCTZ ZESTORETIC PRINZIDE Losartan/HCTZ HYZAAR, SE, QL Olmesartan/HCTZ BENICAR HCT, STEP THERAPY, LIMITED TO #30/MONTH, RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR LOSARTAN/HCTZ IN THE PAST 90 DAYS SE, QL Valsartan/HCTZ DIOVAN HCT, STEP THERAPY, LIMITED TO #30/MONTH, RESTRICTED TO USE AFTER A TRIAL OF LOSARTAN OR LOSARTAN/HCTZ IN THE PAST 90 DAYS Drugs for Pheochromocytoma PA Phenoxybenzamine DIBENZYLINE, PA REQUIRED Potassium-Sparing Diuretics Spironolactone ALDACTONE Spironolactone/HCTZ ALDACTAZIDE Triamterene DYRENIUM Triamterene 37.5mg/HCTZ 25mg DYAZIDE Triamterene 37.5mg/HCTZ 25mg DYAZIDE Triamterene 75mg/HCTZ 50mg MAXZIDE 50 Loop Diuretics Bumetanide BUMEX Furosemide LASIX Thiazide and Related Diuretics Chlorthalidone HYGROTON Hydrochlorothiazide (HCTZ) HYDRODIURIL Indapamide LOZOL Metolazone ZAROXOLYN Vasodilator Antihypertensive Agents Doxazosin Mesylate CARDURA; CARDURAL XL NON-FORMULARY Hydralazine APRESOLINE Minoxidil LONITEN Prazosin MINIPRESS Terazosin HYTRIN

15 Antilipemic Agents Atorvastatin LIPITOR Cholestyramine/Aspartame QUESTRAN LIGHT Cholestyramine/Sucrose QUESTRAN Gemfibrozil LOPID Lovastatin MEVACOR Niacin NIACIN Pravastatin PRAVACHOL Niacin, Delayed Release NIASPAN Niacin/Lovastatin ADVICOR Simvastatin ZOCOR, 80MG STRENGTH RESTRICTED TO PRIOR USE OF 80MG DUE TO MYOPATHY RISK; ALL OTHER STRENGTHS FORMULARY Blood Agents Coagulants and Anticoagulants QL Enoxaparin LOVENOX, LIMITED TO #20/FILL TIMES 3 Warfarin Sodium COUMADIN Hemorheologic Agents Pentoxifylline TRENTAL Cardiac Glycoside Agents Digoxin LANOXIN; LANOXICAPS NON-FORMULARY Antiplatelet Agents Cilostazole PLETAL Clopidogrel PLAVIX Dipyridamole PERSANTINE Pasugrel EFFIENT Vasodilating Agents Isosorbide Dinitrate ISORDIL; CHEW TABLETS NON-FORMULARY Isosorbide Dinitrate SR DILATRATE SR Isosorbide Mononitrate ISOSORBIDE MONONITRATE Isosorbide Dinitrate ER ISOSORBIDE MONONITRATE Nitroglycerin Ointment NITROL Nitroglycerin Patches NITRO-DUR Nitroglycerin Spray NITROLINGUAL SPRAY Nitroglycerin Sublingual NITROSTAT SL SE Isosorbide Mononitrate IMDUR, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF ISOSORBIDE DINITRATE OR ISOSORBIDE DINITRATE SR IN THE PAST 90 DAYS

GASTROINTESTINAL AGENTS

Antidiarrheal Agents Attapulgite PAREPECTOLIN Bismuth Subsalicylate PEPTO BISMOL

16 Diphenoxylate/Atropine LOMOTIL Kaolin/Pectin KAOPECTATE

Loperamide IMODIUM Antiemetic Agents Meclizine ANTIVERT Metoclopramide REGLAN Ondansetron ODT Tablets ZOFRAN ODT Ondansetron Tablets ZOFRAN TABLETS Ondansetron Solution ZOFRAN SOLUTION Prochlorperazine Maleate COMPAZINE COMPAZINE SPANSULES NOT COVERED Promethazine PHENERGAN Trimethobenzamide TIGAN Antimuscarinic/Antispasmodic Agents Belladonna/Phenobarbital DONNATAL (Extentabs, Capsules Not Covered) Chlordiazepoxide/Clidinium CHLORDIAZEPOXIDE/CLIDINIUM Dicyclomine BENTYL Hyoscyamine Sulfate LEVBID LEVSIN LEVSIN SL Antiulcer/Antipeptic Agents Antacid Mg OH/Al OH MAALOX, TC Antacid Mg OH/Al OH/Simethicone MYLANTA I, II Lansoprazole 15mg OTC PREVACID 24HR, LEGEND LANSOPRAZOLE NON-FORMULARY Misoprostol CYTOTEC Omeprazole 20mg and 40mg PRILOSEC 20MG AND 40MG, OTHER STRENGTHS NON- FORMULARY Omeprazole Magnesium PRILOSEC OTC Pantoprazole Tablets PROTONIX Simethicone MYLICON Sucralfate CARAFATE Bowel Evacuant Agents QL Bowel Evacuation Prep Kits FLEET PREP KIT 1, LIMITED TO #2 KITS/MONTH AND 4 FILLS PER YEAR FLEET PREP KIT 2, LIMITED TO #2 KITS/MONTH AND 4 FILLS PER YEAR FLEET PREP KIT 3, LIMITED TO #2 KITS/MONTH AND 4 FILLS PER YEAR QL Enema FLEET ENEMA, LIMITED TO #2 ENEMAS/MONTH AND 4 FILLS PER YEAR Oral Colon Lavage Solution COLYTE QL Oral Saline Laxative FLEET PHOSPHO-SODA, LIMITED TO #2 BOTTLES/MONTH AND 4 FILLS PER YEAR Digestive Enzymes Amylase/Lipase/Protease PANCRELIPASE 5,000 Amylase/Lipase/Protease CREON

17 Amylase/Lipase/Protease PANCREAZE Gallstone Solubilizing Agents Ursodiol ACTIGALL Gastrointestinal Stimulant Agents Metoclopramide REGLAN

H2 Antagonist Agents Cimetidine TAGAMET Famotidine PEPCID Ranitidine ZANTAC (TABLETS ONLY) Laxative Agents QL Bisacodyl Suppositories DULCOLAX, LIMITED TO #30/MONTH Docusate Sodium Capsules COLACE QL Lactulose CEPHULAC, LIMITED TO 4L/MONTH QL CHRONULAC, LIMITED TO 4L/MONTH Sennosides SENNA Miscellaneous Gastrointestinal Supplies Ostomy Supplies

Miscellaneous Gastrointestinal Agents Mesalamine DELZICOL ROWASA Olsalazine DIPENTUM Sulfasalazine AZULFIDINE PA Budesonide ENTOCORT EC, PA REQ

ANTI-INFECTIVE AGENTS

Amebicides Metronidazole FLAGYL; FLAGYL ER NON-FORMULARY Iodoquinol (Diiodohydroxyquin) YODOXIN Antihelmintic Agents Albendazole ALBENZA Furazolidone FUROXONE Mebendazole VERMOX Praziquantel BILTRICIDE Antibiotic Agents Aminoglycosides Neomycin Sulfate MYCIFRADIN

Cephalosporins Cefaclor CECLOR 18 Cefadroxil DURICEF Cefdinir OMNICEF QL Cefixime SUPRAX, LIMITED TO #1 X 400MG/FILL Cefuroxime Tablets CEFTIN Cephalexin KEFLEX; 750MG STRENGTH NON-FORMULARY Macrolide Antibiotic Agents QL Azithromycin ZITHROMAX, LIMITED TO A 5-DAY SUPPLY; ZMAX NON- FORMULARY Erythromycin Base ERY-TAB PCE ERYPED SUSPENSION Erythromycin Stearate ERYTHROCIN Erythromycin Ethylsuccinate EES Erythromycin/Sulfisoxazole PEDIAZOLE PA Clarithromycin BIAXIN, PA REQ Miscellaneous Antibiotic Agents Clindamycin CLEOCIN Metronidazole FLAGYL Penicillins Amoxicillin AMOXIL TRIMOX Amoxicillin/Potassium Clavulanate AUGMENTIN Ampicillin PRINCIPEN Dicloxacillin DYNAPEN Penicillin VK (125mg Tablets Not PEN VK Covered) Quinolones QL Ciprofloxacin tablets CIPRO TABLETS ONLY, LIMITED TO 21-DAY SUPPLY; CIPRO XR AND PROQUIN XR NONFORMULARY QL Moxifloxacin AVELOX, LIMITED TO 21-DAY SUPPLY Sulfonamide Agents Erythromycin/Sulfisoxazole PEDIAZOLE Sulfamethoxazole/Trimethoprim BACTRIM (SMZ/TMP) SEPTRA Sulfisoxazole GANTRISIN Sulfadiazine SULFADIAZINE Trimethoprim TRIMPEX

Tetracyclines Doxycycline VIBRAMYCIN VIBRA-TABS DORYX, PERIOSTAT, AND ORACEA NON-FORMULARY Minocycline MINOCIN Tetracycline ACHROMYCIN V SUMYCIN Antifungal Agents Clotrimazole MYCELEX TROCHE Fluconazole DIFLUCAN Griseofulvin Ultramicrosized GRIS-PEG FULVICIN P/G Ketoconazole NIZORAL Nystatin (Oral Powder Not Covered) MYCOSTATIN Terbinafine Tablets LAMISIL TABLETS

19 Antimalarial Agents Atovaquone/Proguanil MALARONE Chloroquine Phosphate CHLOROQUINE PHOSPHATE Hydroxychloroquine PLAQUENIL Iodoquinol YODOXIN Mefloquine LARIAM Primaquine PRIMAQUINE Pyrimethamine DARAPRIM Quinine (260mg Not Covered) QUININE Antituberculosis Agents Ethambutol MYAMBUTOL Isoniazid ISONIAZID Pyrazinamide PYRAZINAMIDE Rifabutin MYCOBUTIN Rifampin RIFADIN Anti-Ulcer Eradication Agents QL Amoxicillin/Clarithromycin/Lansoprazole PREVPAC, LIMITED TO 14-DAY SUPPLY/YEAR QL Tetracycline/Bismuth/Metronidazole HELIDAC, LIMITED TO 14-DAY SUPPLY/YEAR

Other Antiviral Agents Amantadine SYMMETREL Acyclovir Oral ZOVIRAX ORAL Oseltamivir TAMIFLU, QTY LIMITED TO A 5-DAY COURSE OF TREATMENT OF EITHER TAMIFLU OR RELENZA PER 6 MONTHS Rimantadine FLUMADINE Zanamivir RELENZA, QTY LIMITED TO A 5-DAY COURSE OF TREATMENT OF EITHER RELENZA OR TAMIFLU PER 6 MONTHS Valacyclovir VALTREX SE Famciclovir FAMVIR, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF ACYCLOVIR IN THE PAST 90 DAYS

Leprostatic Agents Clofazimine LAMPRENE Dapsone DAPSONE; ACZONE NON-FORMULARY

RESPIRATORY/EENT AGENTS

Antihistamine Agents Single Entity Alkylamine Agents Chlorpheniramine CHLORTRIMETON Dexchlorpheniramine POLARAMINE Single Entity Ethanolamine Agents Cyproheptadine PERIACTIN Diphenhydramine BENADRYL Non-Sedating Single Entity Agents Cetirizine, OTC CETIRIZINE, OTC Fexofenadine FEXOFENADINE Loratadine, OTC LORATADINE, OTC

20 Miscellaneous Antihistamine Agents Hydroxyzine ATARAX Hydroxyzine Pamoate VISTARIL Promethazine PHENERGAN

Antihistamine/Decongestant Combination Agents Antihistamine/Decongestant Agents Bromphen/Pseudoephedrine BROMFED BROMFED PD Guaifenesin/Pseudoephedrine GUAIFED-PD Pseudoephedrine/Chlorpheniramine DECONAMINE SR

Antitussive Agents Non-Narcotic Antitussive Agents Benzonatate TESSALON Dextromethorphan TUSSIN PEDIATRIC Promethazine/Dextromethorphan PHENERGAN W/DEXTROMETHORPHAN Narcotic Antitussive Agents Codeine/Chlorpheniramine/ NOVAHISTINE DH Pseudoephedrine Guaifenesin/Codeine ROBITUSSIN A-C Guaifenesin/Codeine/Pseudoephedrine NOVAHISTINE EXPECTORANT ROBITUSSIN DAC Phenylephrine/Hydrocodone/ HISTUSSIN HC Chlorpheniramine ENDAL-HD Promethazine/Codeine PHENERGAN/CODEINE Promethazine/Phenylephrine/Codeine PHENERGAN VC/CODEINE Terpin Hydrate/Codeine TERPIN HYDRATE/CODEINE Triprolidine/Pseudoephedrine/Codeine ACTIFED/CODEINE Decongestants Pseudoephedrine SUDAFED

Asthma/COPD Agents Inhaled Sympathomimetic (Adrenergic) Agents QL Albuterol HFA PROVENTIL HFA , LIMITED TO #2 INHALERS/MONTH, PROAIR HFA, VENTOLIN HFA, AND XOPENEX HFA NON-FORMULARY. QL Albuterol/Ipratropium COMBIVENT RESPIMAT, LIMITED TO #1 INHALER/MONTH QL Formoterol FORADIL, LIMITED TO #60/MONTH Ipratropium ATROVENT HFA QL Pirbuterol Acetate MAXAIR, LIMITED TO #2 INHALERS/MONTH MAXAIR AUTOHALER, LIMITED TO #2 INHALERS/MONTH QL Salmeterol SEREVENT, LIMITED TO #1 INHALER/MONTH OR #60 BLISTERS/MONTH SE, QL Mometasone/Formoterol DULERA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF ORAL INHALED STEROID (IF ASTHMA), ANTICHOLINERGIC, OR ANTICHOLINERGIC/LABA IN THE PAST 90 DAYS, LIMITED TO #1 INHALER/MONTH SE, QL Salmeterol/Fluticasone ADVAIR DISKUS 250/50 STRENGTH ONLY, STEP THERAPY, RESTRICTED TO COPD AFTER A TRIAL ANTICHOLINERGIC OR LABA IN THE PAST 90 DAYS, LIMITED TO #1 INHALER/MONTH

Oral Sympathomimetic (Adrenergic) Agents Albuterol PROVENTIL Albuterol E.R. PROVENTIL REPETABS VOLMAX

21 Metaproterenol Oral ALUPENT Terbutaline Sulfate BRETHINE BRICANYL Inhaled Oral Corticosteroid Agents QL Beclomethasone Inhaler QVAR REDIHALER, LIMITED TO #2 INHALERS/MONTH QL Mometasone Inhaler ASMANEX, LIMITED TO #2 INHALERS/MONTH Leukotriene Receptor Antagonists QL Montelukast SINGULAIR, LIMITED TO #30/MONTH Respiratory Smooth Muscle Relaxant Agents Aminophylline 150mg/5ml Aminophylline Suppositories Theophylline, 80mg/15cc (Alcohol Free) SLO-PHYLLIN 80 Theophylline SLO-PHYLLIN Theophylline, Sustained Release THEO-DUR, SLO-BID, UNIPHYL Expectorant Agents Guaifenesin ROBITUSSIN Guaifenesin/Dextromethorphan ROBITUSSIN DM Guaifenesin/Phenylephrine ENDAL Guaifenesin/Pseudoephedrine ZEPHREX LA Phenylephrine/Promethazine PHENERGAN VC Phenylephrine/Guaifenesin RESCON GC Potassium Iodide SSKI

Mucolytic Agents Acetylcysteine MUCOMYST

Eye, Ear, Nose and Throat (EENT) Preparations Ophthalmic Antibiotic Agents Bacitracin BACITRACIN Dexamethasone/Polymyxin/Neomycin MAXITROL Erythromycin Base ILOTYCIN Gentamicin GARAMYCIN Gentamicin/Prednisolone PRED-G Hydrocortisone/Neomycin/Polymyxin CORTISPORIN OPHTHALMIC Neomycin/Gramicidin/Polymyxin NEOSPORIN OPHTHALMIC Ofloxacin OCUFLOX Polymixin B Sulfate/TMP POLYTRIM Tobramycin TOBREX

Ophthalmic Anti-Inflammatory Agents, Corticosteroid Fluorometholone EFLONE FML FML FORTE Prednisolone Acetate PRED MILD OPHTHALMIC PRED FORTE Prednisolone Phosphate INFLAMASE INFLAMASE FORTE Ophthalmic Anti-Inflammatory Agents, NSAIDs Flurbiprofen Sodium OCUFEN Diclofenac Sodium VOLTAREN Ketorolac Tromethamine ACULAR Ophthalmic Antiviral Agents Trifluridine Ophthalmic Solution VIROPTIC Ophthalmic Beta Blockers

22 Levobunolol BETAGAN Timolol TIMOPTIC Ophthalmic Miotic Agents Brimonidine ALPHAGAN ALPHAGAN P Dorzolamide TRUSOPT Dorzolamide/Timolol COSOPT Echothiophate Iodide PHOSPHOLINE IODIDE Pilocarpine PILOCAR OCUSERT NOT COVERED Ophthalmic Mydriatic Agents Atropine Sulfate ISOPTO ATROPINE Dipivefrin PROPINE Tropicamide MYDRIACYL Ophthalmic Sulfonamide Agents Sulfacetamide BLEPH-10 SODIUM SULAMYD Sulfacetamide 10%/Prednisolone 0.2% BLEPHAMIDE Sulfacetamide 10%/Prednisolone 0.5% METIMYD Miscellaneous Ophthalmic Agents Ketotifen ZADITOR OTC, ALAWAY Latanoprost XALATAN Naphazoline ALBALON Naphazoline/Pheniramine NAPHCON-A Otic Anti-Infective Agents Acetic Acid VOSOL Acetic Acid 2% DOMEBORO Acetic Acid 2%/Hydrocortisone 1% VOSOL HC Hydrocortisone/Neomycin/Polymyxin CORTISPORIN Ofloxacin FLOXIN OTIC Miscellaneous Otic Agents Benzocaine/Antipyrine AURALGAN Carbamide Peroxide/Glycerin DEBROX

Inhaled/Oral EENT Agents Inhaled Nasal Agents Fluticasone, Nasal FLONASE Triamcinolone, Nasal NASACORT QL Ipratropium, Nasal ATROVENT, LIMITED TO #2 DEVICES/MONTH Carbonic Anhydrase Inhibitor Agents Acetazolamide DIAMOX Acetazolamide SA DIAMOX SEQUELS Methazolamide NEPTAZANE Local Anesthetic Agents Benzocaine/Antipyrine Otic AURALGAN Lidocaine Solution XYLOCAINE Lidocaine, Viscous VISCOUS XYLOCAINE Triamcinolone 0.1% in Orabase KENALOG IN ORABASE Miscellaneous EENT Agents Carbachol ISOPTO CARBACHOL Chlorhexidine Gluconate PERIDEX Cromolyn Ophthalmic Solution CROLOM Epinephrine Injection EPIPEN QL Optichamber OPTICHAMBER, LIMITED TO #2/YEAR

23 Sodium Chloride for Inhalation GENERIC Triethanolamine CERUMENEX DIABETES AND THYROID AGENTS

Oral Diabetes Agents Sulfonylureas Glipizide GLUCOTROL Glipizide L.A. GLUCOTROL XL Glyburide DIABETA, GLYNASE MICRONASE Glimepiride AMARYL Chlorpropamide DIABINESE Tolazamide TOLINASE Tolbutamide ORINASE Non-Sulfonylureas Acarbose PRECOSE Metformin GLUCOPHAGE Metformin ER GLUCOPHAGE XR Pioglitazone ACTOS SE, QL Alogliptin NESINA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF METFORMIN IN THE PAST 365 DAYS , LIMITED TO 30 TABLETS/MONTH SE, QL Sitagliptin JANUVIA, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF METFORMIN IN THE PAST 365 DAYS , LIMITED TO 30 TABLETS/MONTH

Combination Diabetes Agents Glipizide/Metformin METAGLIP Glyburide/Metformin GLUCOVANCE SE, QL Alogliptin/Metformin KAZANO, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF METFORMIN OR ALOGLIPTIN IN THE PAST 365 DAYS, LIMITED TO 60 TABLETS/MONTH SE, QL Sitagliptin/Metformin JANUMET, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF METFORMIN OR JANUVIA IN THE PAST 365 DAYS, LIMITED TO 60 TABLETS/MONTH SE, QL Sitagliptin/Metformin Extended Release JANUMET XR, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF METFORMIN OR JANUVIA IN THE PAST 365 DAYS, LIMITED TO 30 TABLETS/MONTH EXCEPT JANUMET XR 50- 1000, WHICH IS LIMITED TO 60 TABLETS/MONTH

Insulin Agents Insulin ALL LILLY INSULINS, VIALS ONLY Insulin Lispro HUMALOG, HUMALOG MIX, VIALS AND PENS Insulin Glargine LANTUS, VIALS ONLY Miscellaneous Diabetes Agents Glucagon GLUCAGON

Thyroid Agents Levothyroxine LEVOTHROID Liotrix THYROLAR Liothyronine CYTOMEL

24 Thyroid, Desiccated ARMOUR THYROID LEVOXYL SYNTHROID Antithyroid Agents Methimazole TAPAZOLE Propylthiouracil PROPYLTHIOURACIL

HORMONE AGENTS

Oral Adrenal Corticosteroid Agents Cortisone Acetate CORTONE Dexamethasone DECADRON Fludrocortisone Acetate FLORINEF Hydrocortisone Oral CORTEF Methylprednisolone MEDROL Prednisone DELTASONE ORASONE MEDROL DOSEPAK Prednisolone PEDIAPRED PRELONE

Androgen Agents Danazol DANOCRINE Fluoxymesterone HALOTESTIN Methyltestosterone ANDROID METANDREN

Bone Resorption Inhibitors QL Alendronate FOSAMAX, 70MG AND 35MG LIMITED TO #4/MONTH; 5MG, 10MG, AND 40MG LIMITED TO #30/MONTH; SOLUTION LIMITED TO #300ML/MONTH FOSAMAX PLUS D NONFORMULARY PA Calcitonin MIACALCIN NS, PA REQ Parathyroid Hormone

PA, QL Teriparatide FORTEO, PA REQ, LIMITED TO 1 PEN/MONTH

Estrogen Agents Conjugated Estrogens PREMARIN Conjugated Estrogens, Vaginal PREMARIN VAGINAL CREAM Estradiol ESTRACE Estradiol Patches ALORA CLIMARA ESTRADERM VIVELLE VIVELLE DOT Estrogen/Medroxyprogesterone PREMPRO, PREMPRO LOW DOSE PREMPHASE Esterified Estrogens/ Methyltestosterone ESTRATEST, ESTRATEST HS SE Estradiol/Vaginal Ring ESTRING, STEP THERAPY, RESTRICTED TO USE AFTER A TRIAL OF PREMARIN VAGINAL CREAM IN THE PAST 90 DAYS

25 Estrogen Agonist-Antagonists Raloxifene EVISTA Contraceptives Contraceptives are not a covered benefit.

Oxytocic Agents Ergonovine Maleate ERGOTRATE Methylergonovine Maleate METHERGINE

Pituitary Agents Desmopressin DDAVP

Progestin Agents Medroxyprogesterone CYCRIN PROVERA Norethindrone Acetate AYGESTIN NORLUTATE

GENITOURINARY AGENTS

Urinary Anti-Infective Agents Meth/Me Blue/PA/Salol/ATP/Hyos URISED Nitrofurantoin (Tablets, Suspension FURADANTIN Only) Trimethoprim TRIMPEX

Urinary Anti-Spasmodic Agents Pentosan ELMIRON Phenazopyridine PYRIDIUM

Genitourinary Smooth Muscle Relaxant Agents Belladonna/Methylene Blue URISED Oxybutynin DITROPAN DITROPAN XL NOT COVERED ST, QL Tolterodine DETROL, STEP THERAPY, LIMITED TO #60/MONTH, RESTRICTED TO USE AFTER A TRIAL OF OXYBUTININ IN THE PAST 90 DAYS ST, QL DETROL LA, STEP THERAPY, LIMITED TO #30/MONTH, RESTRICTED TO USE AFTER A TRIAL OF OXYBUTININ IN THE PAST 90 DAYS

Parasympathomimetic (Cholinergic) Agents Bethanechol URECHOLINE Neostigmine PROSTIGMIN Pyridostigmine MESTINON

26 TOPICAL/MUCOUS MEMBRANE AGENTS

Keratolytic Agents Anthralin DRITHOCREME DRITHO-SCALP Podofilox CONDYLOX

Miscellaneous Skin/Mucous Membrane Agents Aluminum Acetate BURROWS SOLUTION Aluminum Chloride Hexahydrate DRYSOL Benzoyl Peroxide, OTC Generic BENZOYL PEROXIDE, OTC GENERIC Calamine CALAMINE LOTION Calcipotriene DOVONEX Fluorouracil EFUDEX Hydrocortisone 1% Rectal PROCTOCORT Masoprocol ACTINEX PA Becaplermin REGRANEX, PA REQ PA Isotretinoin ACCUTANE, PA REQ

Topical Antibiotic Agents Bacitracin BACITRACIN Bacitracin/Polymixin/Neomycin NEOSPORIN Clindamycin Solution CLEOCIN T Erythromycin Topical ERYGEL EMGEL T-STAT Erythromycin/Benzoyl Peroxide BENZAMYCIN Gentamicin Sulfate GARAMYCIN Mupirocin BACTROBAN Silver Sulfadiazine SILVADENE

Topical Antifungal Agents Clotrimazole LOTRIMIN Clotrimazole/Betamethasone LOTRISONE Ciclopirox LOPROX Ketoconazole NIZORAL Miconazole Nitrate MONISTAT-DERM Nystatin MYCOSTATIN Terbinafine LAMISIL Tolnaftate TINACTIN Triamcinolone/Nystatin MYCOLOG II

Vaginal Antifungal Agents Butoconazole FEMSTAT Clotrimazole Cream/Vaginal Tablets MYCELEX MYCELEX G Nystatin MYCOSTATIN Miconazole Cream/Vaginal Tablets MONISTAT MONISTAT 3 Triple Sulfa Cream SULTRIN Tioconazole VAGISTAT-1

27 Vaginal Anti-Infective Agents Metronidazole METROGEL-VAGINAL Topical Anti-Inflammatory Agents LOW POTENCY Fluocinolone 0.025% SYNALAR Desonide TRIDESILON Hydrocortisone HYTONE Hydrocortisone Enema CORTENEMA Hydrocortisone Acetate CORTIFOAM Hydrocortisone/Pramoxine PROCTOCREAM-HC MEDIUM POTENCY Betamethasone Dipropionate DIPROSONE MAXIVATE Betamethasone Valerate 0.01% VALISONE REDUCED STRENGTH Betamethasone Valerate 0.1% VALISONE Desoximetasone Cream/Gel 0.05% TOPICORT LP Flurandrenolide CORDRAN Hydrocortisone Valerate WESTCORT Mometasone Furoate Cream ELOCON Triamcinolone ARISTOCORT ARISTOCORT A NOT COVERED KENALOG HIGH POTENCY Betamethasone Dipropionate DIPROLENE Desoximetasone 0.25% TOPICORT Fluocinonide LIDEX LIDEX E Fluocinolone Acetonide 0.2% SYNALAR VERY HIGH POTENCY Augmented Betamethasone DIPROLENE AF Dipropionate Clobetasol Cream, Gel, Solution, TEMOVATE Ointment Diflorasone Diacetate FLORONE FLORONE-E PSORCON

Topical Antipruritic and Local Anesthetic Agents Lidocaine (Viscous and Spray Only) XYLOCAINE Pramoxine/Hydrocortisone PROCTOFOAM HC Pramoxine EPIFOAM PA Pimecrolimus ELIDEL, PA REQ PA Tacrolimus PROTOPIC, PA REQ

Topical Antiviral Agents Acyclovir Topical ZOVIRAX OINTMENT

Topical Miscellaneous Anti-Infective Agents Selenium Sulfide 2.5% EXSEL SELSUN Sulfacetamide Lotion SEBIZON

28 Scabicide/Pediculicide Agents Crotamiton EURAX Malathion OVIDE Permethrin ELIMITE NIX

MISCELLANEOUS/UNCLASSIFIED AGENTS

Electrolyte Agents Miscellaneous Agents Calcium Acetate PHOS LO Calcium Carbonate TUMS Magnesium Oxide, OTC Generic MAGNESIUM OXIDE, OTC GENERIC Potassium Agents Potassium Chloride 8mEq Potassium Chloride MICRO-K Potassium Chloride 10mEq Potassium Chloride KAON-CL 10 K-DUR MICRO-K 10 Potassium Chloride 20mEq Potassium Chloride K-DUR

29

Potassium Chloride Effervescent Tablets Potassium Chloride Tablets K-LYTE Potassium Chloride Tablets K-LYTE CL DS Potassium Chloride Powders Potassium Chloride Powder K-LOR Potassium Chloride Liquids Potassium Chloride Liquid KAON-CL Potassium-Removing Resins Sodium Polystyrene Sulfonate KAYEXALATE

Heavy Metal Antagonist Agents Penicillamine CUPRIMINE

Vitamin Agents Vitamin B-Complex Agents Cyanocobalamin VITAMIN B12 (ORAL FORMULATIONS ONLY) Folic Acid FOLIC ACID Niacin NIACIN Pyridoxine VITAMIN B6 Thiamine VITAMIN B1 Vitamin D Calcitriol ROCALTROL Ergocalciferol DRISDOL Vitamin K Activity Agents Phytonadione MEPHYTON Iron Agents Ferrous Sulfate (Tablets, Liquid, Drops) FEOSOL Diagnostic Testing Blood Glucose Supplies QL Alcohol Swabs LIMITED TO 200/MONTH Blood Glucose Monitoring Control BLOOD GLUCOSE MONITORING CONTROL SOLUTION, ROCHE Solution PRODUCTS (E.G., ACCU-CHEK) ONLY QL Blood Glucose Test Strips BLOOD GLUCOSE TEST STRIPS, ROCHE STRIPS (E.G., ACCU- CHEK) ONLY, LIMITED TO 100 STRIPS/MONTH FOR MEMBERS THAT ARE DIET-CONTROLLED OR ON ORAL AGENTS. MEMBERS ON INSULIN LIMITED TO 150 STRIPS/MONTH. LARGER QUANTITIES AVAILABLE VIA PRIOR AUTHORIZATION Glucometers GLUCOMETERS, ROCHE METERS (E.G., ACCU-CHEK) ONLY Lancets

Alcohol And Smoking Deterrent Agents PA Bupropion SR ZYBAN, PA REQ Disulfiram ANTABUSE PA Nicotine NICORETTE GUM, PA REQ PA NICOTINE PATCH, PA REQ (OTC PATCHES ONLY) PA NICOTROL NASAL SPRAY, PA REQ

Gout Agents Allopurinol ZYLOPRIM

30 QL Colchicine COLCRYS, LIMITED TO 1 TABLET/DAY. PATIENTS WHO FAIL 1 TABLET/DAY MAY RECEIVE 2 TABLETS/DAY. Probenecid BENEMID

Other Medical Supplies Limited medical supplies are available through the pharmacy benefit. For additional information, contact MedImpact at (800) 788-2949. The following exceptions should be noted:  Durable medical equipment (e.g., wheelchairs, walkers, canes, crutches) are filled through the medical benefit. Path to Health does not provide coverage for contraceptive medical supplies (e.g., diaphragms, cervical caps, condoms).

31 INDEX

Aminoglycosides, 18 —A— Aminophylline 150mg/5ml, 22 Aminophylline Suppositories, 22 ABILIFY, 13 Amiodarone, 14 Acarbose, 24 Amitriptyline, 12 ACCUTANE, 27 Amlodipine, 15 Acetaminophen, 11 Amoxapine, 12 Acetaminophen/Codeine, 11 Amoxicillin, 19 Acetaminophen/Hydrocodone, 11 Amoxicillin/Clarithromycin/Lansoprazole, 20 Acetazolamide, 23 Amoxicillin/Potassium Clavulanate, 19 Acetazolamide SA, 23 AMOXIL, 19 Acetic Acid, 23 Ampicillin, 19 Acetic Acid 2%, 23 Amylase/Lipase/Protease, 17 Acetic Acid 2%/Hydrocortisone 1%, 23 ANAFRANIL, 13 Acetylcysteine, 22 Analgesic and Anti-Inflammatory Agents, 10 ACHROMYCIN V, 19 ANAPROX, 10 ACTIFED/CODEINE, 21 ANAPROX DS, 10 ACTIGALL, 18 Androgen Agents, 25 ACTINEX, 27 ANDROID, 25 ACTOS, 24 Angiotensin Converting Enzyme Inhibitor Agents, 14 ACULAR, 22 Angiotensin Receptor Blocker Agents, 14 Acyclovir Oral, 20 ANTABUSE, 30 Acyclovir Topical, 28 Antacid Mg OH/Al OH, 17 ADALAT CC, 15 Antacid Mg OH/Al OH/Simethicone, 17 ADVAIR DISKUS 250/50 STRENGTH ONLY, 21 Anthralin, 27 ADVICOR, 16 Antiarrhythmic Agents, 14 ALAWAY, 23 Antibiotic Agents, 18 ALBALON, 23 Anticonvulsant Agents, 11 Albendazole, 18 Antidiarrheal Agents, 16 ALBENZA, 18 Antidysrhythmic Drug Agents, 14 Albuterol, 21 Antiemetic Agents, 17 Albuterol E.R., 21 Antifungal Agents, 19 Albuterol HFA, 21 Antihelmintic Agents, 18 Albuterol/Ipratropium, 21 Antihistamine Agents, 20 Alcohol And Smoking Deterrent Agents, 30 Antihistamine/Decongestant Agents, 21 Alcohol Swabs, 30 Antihistamine/Decongestant Combination Agents, 21 ALDACTAZIDE, 15 Antihypertensive Agents, 14 ALDACTONE, 15 ANTI-INFECTIVE AGENTS, 18 ALDOMET, 15 Antilipemic Agents, 16 Alendronate, 25 Antimalarial Agents, 20 Allopurinol, 30 Antimanic Agents, 13 Alogliptin, 24 Antimuscarinic/Antispasmodic Agents, 17 ALORA, 25 Antiparkinsonian Agents, 12 Alpha-Adrenergic Antagonist Antihypertensive Agents, Antiplatelet Agents, 16 14 Antipsychotic Agents, 13 ALPHAGAN, 23 Antipsychotic/SSRI Combination Agents, 13 Alprazolam, 13 Antithyroid Agents, 25 Aluminum Acetate, 27 Antituberculosis Agents, 20 Aluminum Chloride Hexahydrate, 27 Antitussive Agents, 21 ALUPENT, 22 Anti-Ulcer Eradication Agents, 20 Amantadine, 12, 20 Antiulcer/Antipeptic Agents, 17 AMARYL, 24 ANTIVERT, 17 AMBIEN, 14 Antiviral Agents, Other, 20 Amebicides, 18 APAP/Dichloralphenazone/Isometheptene, 10 AMERGE, 10 APRESOLINE, 15

32 ARAVA, 10 Benztropine Mesylate, 12 ARICEPT, 11 Beta-Adrenergic Antagonist Agents, 14 Aripiprazole, 13 BETAGAN, 23 ARISTOCORT, 28 Betamethasone Dipropionate, 28 ARMOUR THYROID, 25 Betamethasone Valerate 0.01%, 28 ARTANE, 12 Betamethasone Valerate 0.1%, 28 Asenapine, 13 BETAPACE, 14 ASENDIN, 12 Bethanechol, 26 ASMANEX, 22 BIAXIN, 19 ASPIRIN, 10 BILTRICIDE, 18 Aspirin, 10 Bisacodyl Suppositories, 18 Aspirin EC, 10 Bismuth Subsalicylate, 16 Asthma/COPD Agents, 21 Bisoprolol/HCTZ, 15 ATARAX, 13, 21 BLEPH-10, 23 Atenolol, 14 BLEPHAMIDE, 23 Atenolol/Chlorthalidone, 15 Blood Agents, 16 ATIVAN, 13 Blood Glucose Monitoring Control Solution, 30 Atorvastatin, 16 Blood Glucose Supplies, 30 Atovaquone/Proguanil, 20 Blood Glucose Test Strips, 30 Atropine Sulfate, 23 Bone Resorption Inhibitors, 25 ATROVENT, 23 Bowel Evacuant Agents, 17 ATROVENT HFA, 21 Bowel Evacuation Prep Kits, 17 Attapulgite, 16 BRETHINE, 22 Augmented Betamethasone Dipropionate, 28 BRICANYL, 22 AUGMENTIN, 19 Brimonidine, 23 AURALGAN, 23 BROMFED, 21 AVAPRO, 14 Bromocriptine, 12 AVELOX, 19 Bromphen/Pseudoephedrine, 21 AYGESTIN, 26 Budesonide, 18 Azithromycin, 19 Bumetanide, 15 AZULFIDINE, 18 BUMEX, 15 Bupropion, 13 —B— Bupropion SR, 13, 30 Bupropion XL, 13 Bacitracin, 22, 27 BURROWS SOLUTION, 27 Bacitracin/Polymixin/Neomycin, 27 BUSPAR, 13 Baclofen, 12 Buspirone, 13 BACTRIM, 19 Butalbital/APAP/Caffeine, 10 BACTROBAN, 27 Butalbital/APAP/Caffeine/Codeine, 11 Barbiturate Anticonvulsants, 11 Butalbital/Aspirin/Caffeine, 10 Becaplermin, 27 Butalbital/Aspirin/Caffeine/Codeine, 11 Beclomethasone Inhaler, 22 Butoconazole, 27 Belladonna/Methylene Blue, 26 Butorphanol NS, 11 Belladonna/Phenobarbital, 17 BENADRYL, 20 —C— Benazepril, 14 Benazepril/HCTZ, 15 CAFERGOT, 10 BENEMID, 31 Calamine, 27 BENICAR, 14 CALAMINE LOTION, 27 BENICAR HCT, 15 CALAN, 15 BENTYL, 17 CALAN SR, 15 BENZAMYCIN, 27 Calcipotriene, 27 Benzocaine/Antipyrine, 23 Calcitonin, 25 Benzocaine/Antipyrine Otic, 23 Calcitriol, 30 Benzodiazepine Anticonvulsants, 11 Calcium Acetate, 29 Benzodiazepines, 13 Calcium Carbonate, 29 Benzonatate, 21 Calcium Channel Blocking Agents, 15 BENZOYL PEROXIDE, OTC GENERIC, 27 CAPOTEN, 14 Benzoyl Peroxide, OTC Generic, 27 CAPOZIDE, 15

33 Captopril, 14 Citalopram, 12 Captopril/HCTZ, 15 Clarithromycin, 19 CARAFATE, 17 CLEOCIN, 19 Carbachol, 23 CLEOCIN T, 27 Carbamazepine, 11 CLIMARA, 25 Carbamazepine Extended Release, 11 Clindamycin, 19 Carbamide Peroxide/Glycerin, 23 Clindamycin Solution, 27 Carbidopa/Levodopa, 12 CLINORIL, 10 Carbidopa/Levodopa CR, 12 Clobetasol Cream, Gel, Solution, Ointment, 28 Carbonic Anhydrase Inhibitor Agents, 23 Clofazimine, 20 Cardiac Glycoside Agents, 16 Clomipramine, 13 CARDIOQUIN, 14 Clonazepam, 11 CARDIOVASCULAR/BLOOD AGENTS, 14 Clonidine, 15 CARDIZEM, 15 Clopidogrel, 16 CARDIZEM SR, 15 Clorazepate, 13 CARDURA, 15 Clotrimazole, 19, 27 Carisoprodol, 12 Clotrimazole Cream/Vaginal Tablets, 27 CARTIA XT, 15 Clotrimazole/Betamethasone, 27 Carvedilol, 14 Clozapine, 13 CATAPRES, 15 CLOZARIL, 13 CECLOR, 18 Coagulants and Anticoagulants, 16 Cefaclor, 18 Codeine/Aspirin, 11 Cefadroxil, 19 Codeine/Chlorpheniramine/Pseudoephedrine, 21 Cefdinir, 19 COGENTIN, 12 Cefixime, 19 COLACE, 18 CEFTIN, 19 Colchicine, 31 Cefuroxime, 19 COLCRYS, 31 CELEBREX, 10 COLYTE, 17 Celecoxib, 10 Combination Alpha-Beta Antagonist Agents, 14 CELEXA, 12 Combination Antihypertensive Agents, 15 CENTRAL NERVOUS SYSTEM AGENTS, 10 Combination Diabetes Agents, 24 Centrally Acting Antihypertensive Agents, 15 COMBIVENT RESPIMAT, 21 Cephalexin, 19 COMPAZINE, 17 Cephalosporins, 18 CONDYLOX, 27 CEPHULAC, 18 Conjugated Estrogens, 25 CERUMENEX, 24 Conjugated Estrogens, Vaginal, 25 Cetirizine OTC, 20 CORDARONE, 14 CETIRIZINE, OTC, 20 CORDRAN, 28 Chloral Hydrate, 13 COREG, 14 Chlordiazepoxide, 13 CORGARD, 14 Chlordiazepoxide/Clidinium, 17 CORTEF, 25 Chlorhexidine Gluconate, 23 CORTENEMA, 28 CHLOROQUINE PHOSPHATE, 20 CORTIFOAM, 28 Chloroquine Phosphate, 20 Cortisone Acetate, 25 Chlorpheniramine, 20 CORTISPORIN, 23 Chlorpromazine, 13 CORTISPORIN OPHTHALMIC, 22 Chlorpropamide, 24 CORTONE, 25 Chlorthalidone, 15 COSOPT, 23 CHLORTRIMETON, 20 COUMADIN, 16 Chlorzoxazone, 12 COZAAR, 14 Cholestyramine/Aspartame, 16 CREON, 17 Cholestyramine/Sucrose, 16 CROLOM, 23 CHRONULAC, 18 Cromolyn Ophthalmic Solution, 23 Ciclopirox, 27 Crotamiton, 29 Cilostazole, 16 CUPRIMINE, 30 Cimetidine, 18 Cyanocobalamin, 30 CIN-QUIN, 14 Cyclobenzaprine, 12 CIPRO, 19 CYCRIN, 26 Ciprofloxacin tablets, 19 CYMBALTA, 12

34 Cyproheptadine, 20 DIPENTUM, 18 CYTOMEL, 24 Diphenhydramine, 20 CYTOTEC, 17 Diphenoxylate/Atropine, 17 Dipivefrin, 23 —D— DIPROLENE, 28 DIPROLENE AF, 28 DALMANE, 13 DIPROSONE, 28 Danazol, 25 Dipyridamole, 16 DANOCRINE, 25 DISALCID, 10 DANTRIUM, 12 Disopyramide, 14 Dantrolene Sodium, 12 Disopyramide CR, 14 DAPSONE, 20 Disulfiram, 30 Dapsone, 20 DITROPAN, 26 DARAPRIM, 20 Divalproex Sodium, 11 DDAVP, 26 Divalproex Sodium Extended Release, 11 DEBROX, 23 Docusate Sodium Capsules, 18 DECADRON, 25 DOMEBORO, 23 DECONAMINE SR, 21 Donepezil, 11 Decongestants, 21 DONNATAL, 17 DELTASONE, 25 Dorzolamide, 23 DELZICOL, 18 Dorzolamide/Timolol, 23 DEPAKENE, 11 DOVONEX, 27 DEPAKOTE, 11 Doxazosin Mesylate, 15 Desipramine, 12 Doxepin, 12 Desmopressin, 26 DOXYCYCLINE, 19 Desonide, 28 DRISDOL, 30 Desoximetasone 0.25%, 28 DRITHOCREME, 27 Desoximetasone Cream/Gel 0.05%, 28 DRITHO-SCALP, 27 DESYREL, 13 Drugs for Pheochromocytoma, 15 DETROL, 26 DRYSOL, 27 DETROL LA, 26 DULCOLAX, 18 Dexamethasone, 25 DULERA, 21 Dexamethasone/Polymyxin/Neomycin, 22 Duloxetine, 12 Dexchlorpheniramine, 20 DURICEF, 19 Dextromethorphan, 21 DYAZIDE, 15 DIABETA, 24 DYNAPEN, 19 DIABETES AND THYROID AGENTS, 24 DYRENIUM, 15 DIABINESE, 24 Diagnostic Testing, 30 —E— DIAMOX, 23 DIAMOX SEQUELS, 23 Echothiophate Iodide, 23 Diazepam, 13 ECOTRIN, 10 DIBENZYLINE, 15 EES, 19 Diclofenac Sodium, 10, 22 EFFEXOR, 12 Dicloxacillin, 19 EFFEXOR XR, 12 Dicyclomine, 17 EFFIENT, 16 Diflorasone Diacetate, 28 EFLONE, 22 DIFLUCAN, 19 EFUDEX, 27 Digestive Enzymes, 17 ELAVIL, 12 Digoxin, 16 Electrolyte Agents, 29 Dihydroergotamine, 10 Eletriptan, 10 DILANTIN, 11 ELIDEL, 28 DILATRATE SR, 16 ELIMITE, 29 DILAUDID, 11 ELMIRON, 26 Diltiazem, 15 ELOCON, 28 Diltiazem CD, 15 EMGEL, 27 Diltiazem SR, 15 EMPIRIN #2, #3, #4, 11 DIOVAN, 14 Enalapril, 14 DIOVAN HCT, 15 Enalapril/HCTZ, 15

35 ENDAL, 22 FIORICET/CODEINE, 11 ENDAL-HD, 21 FIORINAL, 10 Enema, 17 FIORINAL/CODEINE, 11 Enoxaparin, 16 FLAGYL, 18, 19 ENTOCORT EC, 18 Flecainide, 14 EPIFOAM, 28 FLEET ENEMA, 17 Epinephrine Injection, 23 FLEET PHOSPHO-SODA, 17 EPIPEN, 23 FLEET PREP KIT 1, 17 Ergocalciferol, 30 FLEET PREP KIT 2, 17 Ergonovine Maleate, 26 FLEET PREP KIT 3, 17 Ergotamine/Caffeine, 10 FLEXERIL, 12 ERGOTRATE, 26 FLONASE, 23 ERYGEL, 27 FLORINEF, 25 ERYPED SUSPENSION, 19 FLORONE, 28 ERY-TAB, 19 FLORONE-E, 28 ERYTHROCIN, 19 FLOXIN OTIC, 23 Erythromycin Base, 19, 22 Fluconazole, 19 Erythromycin Ethylsuccinate, 19 Fludrocortisone Acetate, 25 Erythromycin Stearate, 19 FLUMADINE, 20 Erythromycin Topical, 27 Fluocinolone, 28 Erythromycin/Benzoyl Peroxide, 27 Fluocinolone 0.025%, 28 Erythromycin/Sulfisoxazole, 19 Fluocinolone Acetonide 0.2%, 28 ESGIC, 10 Fluorometholone, 22 ESGIC PLUS, 10 Fluorouracil, 27 ESKALITH, 13 Fluoxetine Capsules, 12 Esterified Estrogens/Methyltestosterone, 25 Fluoxymesterone, 25 ESTRACE, 25 Fluphenazine, 13 ESTRADERM, 25 Flurandrenolide, 28 Estradiol, 25 Flurazepam, 13 Estradiol Patches, 25 Flurbiprofen Sodium, 22 Estradiol/Vaginal Ring, 25 Fluticasone, Nasal, 23 ESTRATEST, 25 Fluvoxamine, 12 ESTRATEST HS, 25 FML, 22 ESTRING, 25 FML FORTE, 22 Estrogen Agents, 25 FOLIC ACID, 30 Estrogen Agonist-Antagonists, 26 Folic Acid, 30 Estrogen/Medroxyprogesterone, 25 FORADIL, 21 Ethambutol, 20 Formoterol, 21 Etodolac, 10 FORTEO, 25 Etodolac Extended Release, 10 FOSAMAX, 25 EURAX, 29 FULVICIN P/G, 19 EVISTA, 26 FURADANTIN, 26 Expectorant Agents, 22 Furazolidone, 18 EXSEL, 28 Furosemide, 15 Eye, Ear, Nose and Throat (EENT) Preparations, 22 FUROXONE, 18

—F— —G— Famciclovir, 20 Gabapentin, 11 Famotidine, 18 GABITRIL, 11 FAMVIR, 20 Gallstone Solubilizing Agents, 18 FELDENE, 10 GANTRISIN, 19 Felodipine, 15 GARAMYCIN, 22, 27 FEMSTAT, 27 GASTROINTESTINAL AGENTS, 16 FEOSOL, 30 Gastrointestinal Stimulant Agents, 18 Ferrous Sulfate, 30 Gemfibrozil, 16 FEXOFENADINE, 20 GENITOURINARY AGENTS, 26 Fexofenadine, 20 Genitourinary Smooth Muscle Relaxant Agents, 26 FIORICET, 10 Gentamicin, 22

36 Gentamicin Sulfate, 27 Hydroxyzine, 13, 21 Gentamicin/Prednisolone, 22 Hydroxyzine Pamoate, 14, 21 GEODON, 13 HYGROTON, 15 Glimepiride, 24 Hyoscyamine Sulfate, 17 Glipizide, 24 HYTONE, 28 Glipizide L.A., 24 HYTRIN, 15 Glipizide/Metformin, 24 HYZAAR, 15 GLUCAGON, 24 Glucagon, 24 —I— Glucometers, 30 GLUCOPHAGE, 24 Ibuprofen, 10 GLUCOPHAGE XR, 24 ILOTYCIN, 22 GLUCOTROL, 24 IMDUR, 16 GLUCOTROL XL, 24 Imipramine, 12 GLUCOVANCE, 24 IMITREX, 10 Glyburide, 24 IMODIUM, 17 Glyburide/Metformin, 24 Indapamide, 15 GLYNASE, 24 INDERAL, 14 Gout Agents, 30 INDERAL LA, 14 Griseofulvin Ultramicrosize, 19 INDOCIN, 10 GRIS-PEG, 19 INDOCIN SR, 10 GUAIFED-PD, 21 Indomethacin, Sustained Release, 10 Guaifenesin, 22 INFLAMASE, 22 Guaifenesin/Codeine, 21 INFLAMASE FORTE, 22 Guaifenesin/Codeine/Pseudoephedrine, 21 Inhaled Nasal Agents, 23 Guaifenesin/Dextromethorphan, 22 Inhaled Oral Corticosteroid Agents, 22 Guaifenesin/Phenylephrine, 22 Inhaled Sympathomimetic (Adrenergic) Agents, 21 Guaifenesin/Pseudoephedrine, 21, 22 Inhaled/Oral EENT Agents, 23 Guanfacine, 15 Insulin, 24 Insulin Agents, 24 —H— Insulin Glargine, 24 Insulin Lispro, 24 H2 Antagonist Agents, 18 Iodoquinol, 20 HALCION, 13 Iodoquinol (Diiodohydroxyquin), 18 HALDOL, 13 Ipratropium, 21 HALDOL DECANOATE (VIALS ONLY), 13 Ipratropium, Nasal, 23 Haloperidol, 13 Irbesartan, 14 HALOTESTIN, 25 Iron Agents, 30 Heavy Metal Antagonist Agents, 30 ISONIAZID, 20 HELIDAC, 20 Isoniazid, 20 Hemorheologic Agents, 16 ISOPTO ATROPINE, 23 HISTUSSIN HC, 21 ISOPTO CARBACHOL, 23 HORMONE AGENTS, 25 ISORDIL, 16 HUMALOG (VIALS AND PENS), 24 Isosorbide Dinitrate, 16 HUMALOG MIX (VIALS AND PENS), 24 Isosorbide Dinitrate ER, 16 Hydantoin Anticonvulsants, 11 Isosorbide Dinitrate SR, 16 Hydralazine, 15 Isosorbide Mononitrate, 16 Hydrochlorothiazide (HCTZ), 15 Isotretinoin, 27 Hydrocortisone, 28 Hydrocortisone 1% Rectal Cream, 27 —J— Hydrocortisone Acetate, 28 Hydrocortisone Enema, 28 JANUMET, 24 Hydrocortisone Oral, 25 JANUMET XR, 24 Hydrocortisone Valerate, 28 JANUVIA, 24 Hydrocortisone/Neomycin/Polymyxin, 22, 23 Hydrocortisone/Pramoxine, 28 —K— HYDRODIURIL, 15 Hydromorphone, 11 Kaolin/Pectin, 17 Hydroxychloroquine, 20 KAON-CL, 30

37 KAON-CL 10, 29 Lisinopril/HCTZ, 15 KAOPECTATE, 17 Lithium Carbonate, 13 KAYEXALATE, 30 LITHOBID, 13 KAZANO, 24 Local Anesthetic Agents, 23 K-DUR, 29 LODINE, 10 K-DUR, 29 LODINE XL, 10 KEFLEX, 19 LOMOTIL, 17 KENALOG, 28 LONITEN, 15 KENALOG IN ORABASE, 23 Loop Diuretics, 15 KEPPRA, 11 Loperamide, 17 Keratolytic Agents, 27 LOPID, 16 Ketoconazole, 19, 27 LOPRESSOR, 14 Ketoprofen, 10 LOPROX, 27 Ketorolac Tromethamine, 22 Loratadine OTC, 20 Ketotifen, 23 LORATADINE, OTC, 20 KLONOPIN, 11 Lorazepam, 13 K-LOR, 30 Losartan, 14 K-LYTE, 30 Losartan/HCTZ, 15 K-LYTE CL DS, 30 LOTENSIN, 14 LOTENSIN HCT, 15 —L— LOTRIMIN, 27 LOTRISONE, 27 Labetalol, 14 Lovastatin, 16 Lactulose, 18 LOVENOX, 16 LAMICTAL, 11 Loxapine, 13 LAMISIL, 19, 27 LOXITANE, 13 Lamotrigine, 11 LOZOL, 15 LAMPRENE, 20 LUDIOMIL, 12 Lancets, 30 LUVOX, 12 LANOXIN, 16 Lansoprazole 15mg OTC, 17 —M— LANTUS (VIALS ONLY), 24 LARIAM, 20 M.A.O. Inhibitor Agents, 12 LASIX, 15 MAALOX, 17 Latanoprost, 23 MAALOX TC, 17 Laxative Agents, 18 Macrolide Antibiotic Agents, 19 Leflunomide, 10 MAGNESIUM OXIDE, OTC GENERIC, 29 Leprostatic Agents, 20 Magnesium Oxide, OTC Generic, 29 Leukotriene Receptor Antagonists, 22 MALARONE, 20 LEVBID, 17 Malathion, 29 Levetiracetam, 11 Maprotiline, 12 Levobunolol, 23 Masoprocol, 27 LEVOTHROID, 24 MAXAIR, 21 Levothyroxine, 24 MAXAIR AUTOHALER, 21 LEVOXYL, 25 MAXALT, 10 LEVSIN, 17 MAXALT MLT, 10 LEVSIN SL, 17 MAXITROL, 22 LIBRIUM, 13 MAXIVATE, 28 LIDEX, 28 MAXZIDE 50, 15 LIDEX E, 28 MEBARAL, 11 Lidocaine, 28 Mebendazole, 18 Lidocaine Solution, 23 Meclizine, 17 Lidocaine, Viscous, 23 MEDROL, 25 LILLY INSULINS (VIALS ONLY), 24 MEDROL DOSEPAK, 25 LIORESAL, 12 Medroxyprogesterone, 26 Liothyronine, 24 Mefloquine, 20 Liotrix, 24 MELLARIL, 13 LIPITOR, 16 Meloxicam Tablets, 10 Lisinopril, 14 Mephobarbital, 11

38 MEPHYTON, 30 MISCELLANEOUS/UNCLASSIFIED AGENTS, 29 Mesalamine, 18 Misoprostol, 17 MESTINON, 26 MOBAN, 13 METAGLIP, 24 MOBIC (TABLETS ONLY), 10 METANDREN, 25 Molindone, 13 Metaproterenol Oral, 22 Mometasone Furoate Cream, 28 Metformin, 24 Mometasone Inhaler, 22 Metformin ER, 24 Mometasone/Formoterol, 21 Meth/Me Blue/PA/Salol/ATP/Hyos, 26 MONISTAT, 27 Methazolamide, 23 MONISTAT 3, 27 METHERGINE, 26 MONISTAT-DERM, 27 Methimazole, 25 Montelukast, 22 Methocarbamol, 12 Morphine, 11 Methyldopa, 15 Morphine SR, 11 Methylergonovine Maleate, 26 MOTRIN, 10 Methylprednisolone, 25 Moxifloxacin, 19 Methyltestosterone, 25 MS CONTIN/ORAMORPH SR, 11 METIMYD, 23 MSIR, 11 Metoclopramide, 17, 18 Mucolytic Agents, 22 Metolazone, 15 MUCOMYST, 22 Metoprolol Succinate, 14 Mupirocin, 27 Metoprolol Tartrate, 14 Muscle Relaxant Agents, 12 METROGEL-VAGINAL, 28 MYAMBUTOL, 20 Metronidazole, 18, 19, 28 MYCELEX, 27 MEVACOR, 16 MYCELEX G, 27 Mexiletine, 14 MYCELEX TROCHE, 19 MEXITIL, 14 MYCIFRADIN, 18 MIACALCIN NS, 25 MYCOBUTIN, 20 MICARDIS, 14 MYCOLOG II, 27 Miconazole Cream/Vaginal Tablets, 27 MYCOSTATIN, 19, 27 Miconazole Nitrate, 27 MYDRIACYL, 23 MICRO-K, 29 MYLANTA I, 17 MICRO-K 10, 29 MYLANTA II, 17 MICRONASE, 24 MYLICON, 17 MIDRIN, 10 MYSOLINE, 11 Migraine Agents, 10 MIGRANAL, 10 —N— MINIPRESS, 15 MINOCIN, 19 Nabumetone, 10 Minocycline, 19 Nadolol, 14 Minoxidil, 15 Naloxone, 11 MIRAPEX, 12 Naltrexone, 11 Mirtazapine, 13 Naphazoline, 23 Miscellaneous Agents, 29 Naphazoline/Pheniramine, 23 Miscellaneous Analgesics, 11 NAPHCON-A, 23 Miscellaneous Antibiotic Agents, 19 NAPROSYN, 10 Miscellaneous Anticonvulsants, 11 Naproxen, 10 Miscellaneous Antidepressant Agents, 12 Naproxen Sodium, 10 Miscellaneous Antihistamine Agents, 21 Naratriptan, 10 Miscellaneous Anxiolytics, Sedatives, and Hypnotics, 13 NARCAN, 11 Miscellaneous Arthritis Agents, 10 Narcotic Antitussive Agents, 21 Miscellaneous Central Nervous System Agents, 11 Narcotic Withdrawal Therapy Agents, 11 Miscellaneous Diabetes Agents, 24 NARDIL, 12 Miscellaneous EENT Agents, 23 NASACORT, 23 Miscellaneous Gastrointestinal Agents, 18 NAVANE, 13 Miscellaneous Gastrointestinal Supplies, 18 Nefazodone, 13 Miscellaneous Ophthalmic Agents, 23 Neomycin Sulfate, 18 Miscellaneous Otic Agents, 23 Neomycin/Gramicidin/Polymyxin, 22 Miscellaneous Skin/Mucous Membrane Agents, 27 NEOSPORIN, 27

39 NEOSPORIN OPHTHALMIC, 22 Ondansetron ODT Tablets, 17 Neostigmine, 26 Ondansetron Solution, 17 NEPTAZANE, 23 Ondansetron Tablets, 17 NESINA, 24 Ophthalmic Antibiotic Agents,, 22 NEURONTIN, 11 Ophthalmic Anti-Inflammatory Agents, Corticosteroid, 22 NIACIN, 16, 30 Ophthalmic Anti-Inflammatory Agents, NSAIDs, 22 Niacin, 16, 30 Ophthalmic Antiviral Agents, 22 Niacin, Delayed Release, 16 Ophthalmic Beta Blockers, 22 Niacin/Lovastatin, 16 Ophthalmic Miotic Agents, 23 NIASPAN, 16 Ophthalmic Mydriatic Agents, 23 NICORETTE GUM, 30 Ophthalmic Sulfonamide Agents, 23 Nicotine, 30 Opiate Agonists, 10 NICOTINE PATCH, 30 Opiate Antagonists, 11 NICOTROL NASAL SPRAY, 30 OPTICHAMBER, 23 Nifedipine, Sustained Release, 15 Optichamber, 23 NITRO-DUR, 16 Oral Adrenal Corticosteroid Agents, 25 Nitrofurantoin, 26 Oral Colon Lavage Solution, 17 Nitroglycerin Ointment, 16 Oral Contraceptive Agents, 26 Nitroglycerin Patches, 16 Oral Diabetes Agents, 24 Nitroglycerin Spray, 16 Oral Saline Laxative, 17 Nitroglycerin Sublingual, 16 Oral Sympathomimetic (Adrenergic) Agents, 21 NITROL, 16 ORAP, 13 NITROLINGUAL SPRAY, 16 ORASONE, 25 NITROSTAT SL, 16 ORINASE, 24 NIX, 29 Orphenadrine Citrate, 12 NIZORAL, 19, 27 Orphenadrine/Aspirin/Caffeine, 12 NOCTEC, 13 ORUVAIL, 10 Non-Narcotic Antitussive Agents, 21 Oseltamivir, 20 Non-Sedating Single Entity Agents, 20 Ostomy Supplies, 18 Non-Steroidal Anti-Inflammatory Agents, 10 Other Medical Supplies, 31 Non-Sulfonylureas, 24 Otic Anti-Infective Agents, 23 NORCO, 11 OVIDE, 29 Norethindrone Acetate, 26 Oxcarbazepine, 11 NORFLEX, 12 Oxybutynin, 26 NORGESIC, 12 Oxycodone, 11 NORLUTATE, 26 Oxycodone/Acetaminophen, 11 NORMODYNE, 14 Oxycodone/Aspirin, 11 NORPACE, 14 OXYCONTIN, 11 NORPACE CR, 14 OXYFAST, 11 NORPRAMIN, 12 OXYIR, 11 Nortriptyline, 12 Oxytocic Agents, 26 NORVASC, 15 NOVAHISTINE DH, 21 —P— NOVAHISTINE EXPECTORANT, 21 Nystatin, 19, 27 PAMELOR, 12 PANCREAZE, 18 —O— PANCRELIPASE 5,000, 17 Pantoprazole, 17 OCUFEN, 22 PARAFON DSC, 12 OCUFLOX, 22 Parasympathomimetic (Cholinergic) Agents, 26 Ofloxacin, 22, 23 Parathyroid Hormone, 25 Olanzapine, 13 PAREPECTOLIN, 16 Olanzapine/Fluoxetine HCl, 13 PARLODEL, 12 Olmesartan, 14 PARNATE, 12 Olmesartan/HCTZ, 15 Paroxetine, 12 Olsalazine, 18 Pasugrel, 16 Omeprazole 20mg and 40mg, 17 PAXIL, 12 Omeprazole Magnesium, 17 PCE, 19 OMNICEF, 19 PEDIAPRED, 25

40 PEDIAZOLE, 19 Potassium Chloride Powder, 30 PEN VK, 19 Potassium Chloride Powders, 30 Penicillamine, 30 Potassium Chloride Tablets, 30 Penicillin VK, 19 Potassium Iodide, 22 Penicillins, 19 Potassium-Removing Resins, 30 Pentosan, 26 Potassium-Sparing Diuretics, 15 Pentoxifylline, 16 Pramipexole, 12 PEPCID, 18 Pramoxine, 28 PEPTO BISMOL, 16 Pramoxine/Hydrocortisone, 28 PERCOCET, 11 PRAVACHOL, 16 PERCODAN, 11 Pravastatin, 16 PERIACTIN, 20 Praziquantel, 18 PERIDEX, 23 Prazosin, 15 Permethrin, 29 PRECOSE, 24 Perphenazine, 13 PRED FORTE, 22 PERSANTINE, 16 PRED MILD OPHTHALMIC, 22 Phenazopyridine, 26 PRED-G, 22 Phenelzine, 12 Prednisolone, 25 PHENERGAN, 14, 17, 21 Prednisolone Acetate, 22 PHENERGAN VC, 22 Prednisolone Phosphate, 22 PHENERGAN VC/CODEINE, 21 Prednisone, 25 PHENERGAN W/DEXTROMETHORPHAN, 21 PRELONE, 25 PHENERGAN/CODEINE, 21 PREMARIN, 25 PHENOBARBITAL, 11 PREMARIN VAGINAL CREAM, 25 Phenobarbital, 11 PREMPHASE, 25 Phenoxybenzamine, 15 PREMPRO, 25 Phenylephrine/Guaifenesin, 22 PREMPRO LOW DOSE, 25 Phenylephrine/Hydrocodone/Chlorpheniramine, 21 PREVACID 24HR, 17 Phenylephrine/Promethazine, 22 PREVPAC, 20 PHENYTEK, 11 PRILOSEC 20MG AND 40MG, 17 Phenytoin, 11 PRILOSEC OTC, 17 PHOS LO, 29 PRIMAQUINE, 20 PHOSPHOLINE IODIDE, 23 Primaquine, 20 Phytonadione, 30 Primidone, 11 PILOCAR, 23 PRINCIPEN, 19 Pilocarpine, 23 PRINIVIL, 14 Pimecrolimus, 28 PRINZIDE, 15 Pimozide, 13 Probenecid, 31 Pindolol, 14 Procainamide, 14 Pioglitazone, 24 Procainamide SR, 14 Pirbuterol Acetate, 21 PROCAN SR, 14 Piroxicam, 10 PROCANBID, 14 Pituitary Agents, 26 Prochlorperazine Maleate, 17 PLAQUENIL, 20 PROCTOCORT, 27 PLAVIX, 16 PROCTOCREAM-HC, 28 PLENDIL, 15 PROCTOFOAM HC, 28 PLETAL, 16 Progestin Agents, 26 Podofilox, 27 PROLIXIN, 13 POLARAMINE, 20 Promethazine, 14, 17, 21 Polymixin B Sulfate/TMP, 22 Promethazine/Codeine, 21 POLYTRIM, 22 Promethazine/Dextromethorphan, 21 Potassium Agents, 29 Promethazine/Phenylephrine/Codeine, 21 Potassium Chloride, 29 PRONESTYL, 14 Potassium Chloride 10mEq, 29 Propafenone, 14 Potassium Chloride 20mEq, 29 PROPINE, 23 Potassium Chloride 8mEq, 29 Propranolol, 14 Potassium Chloride Effervescent Tablets, 30 Propranolol LA, 14 Potassium Chloride Liquid, 30 PROPYLTHIOURACIL, 25 Potassium Chloride Liquids, 30 Propylthiouracil, 25

41 PROSTIGMIN, 26 Rizatriptan, 10 PROTONIX, 17 ROBAXIN, 12 PROTOPIC, 28 ROBITUSSIN, 22 Protriptyline, 12 ROBITUSSIN A-C, 21 PROVENTIL, 21 ROBITUSSIN DAC, 21 PROVENTIL HFA, 21 ROBITUSSIN DM, 22 PROVENTIL REPETABS, 21 ROCALTROL, 30 PROVERA, 26 Ropinirole, 12 PROZAC CAPSULES, 12 ROWASA, 18 Pseudoephedrine, 21 RYTHMOL, 14 Pseudoephedrine/Chlorpheniramine, 21 PSORCON, 28 —S— Psychotherapeutic Agents, 12 PYRAZINAMIDE, 20 S.N.R.I. Agents, 12 Pyrazinamide, 20 S.S.R.I. Agents, 12 PYRIDIUM, 26 Salmeterol, 21 Pyridostigmine, 26 Salmeterol/Fluticasone, 21 Pyridoxine, 30 Salsalate, 10 Pyrimethamine, 20 SAPHRIS, 13 Scabicide/Pediculicide Agents, 29 —Q— SEBIZON, 28 Selegiline, 12 QUESTRAN, 16 Selenium Sulfide 2.5%, 28 QUESTRAN LIGHT, 16 SELSUN, 28 Quetiapine, 13 SENNA, 18 QUINAGLUTE, 14 Sennosides, 18 QUINIDEX, 14 SEPTRA, 19 Quinidine Gluconate, 14 SEREVENT, 21 Quinidine Polygalacturonate, 14 SEROQUEL, 13 Quinidine Sulfate, 14 SERPASIL, 14 Quinidine Sulfate SR, 14 Sertraline, 12 QUININE, 20 SERZONE, 13 Quinine, 20 SILVADENE, 27 Quinolones, 19 Silver Sulfadiazine, 27 QVAR REDIHALER, 22 Simethicone, 17 Simvastatin, 16 —R— SINEMET, 12 SINEMET CR, 12 Raloxifene, 26 SINEQUAN, 12 Ranitidine, 18 Single Entity Alkylamine Agents, 20 REGLAN, 17, 18 Single Entity Ethanolamine Agents, 20 REGRANEX, 27 SINGULAIR, 22 RELAFEN, 10 Sitagliptin, 24 RELENZA, 20 Sitagliptin/Metformin, 24 RELPAX, 10 Sitagliptin/Metformin Extended Release, 24 REMERON, 13 Skeletal Muscle Relaxants, 12 REQUIP, 12 SLO-BID, 22 RESCON GC, 22 SLO-PHYLLIN, 22 Reserpine, 14 SLO-PHYLLIN 80, 22 Respiratory Smooth Muscle Relaxant Agents, 22 Sodium Chloride for Inhalation, 24 RESPIRATORY/EENT AGENTS, 20 Sodium Polystyrene Sulfonate, 30 RESTORIL, 13 SODIUM SULAMYD, 23 REVIA, 11 SOMA, 12 Rifabutin, 20 Sotalol, 14 RIFADIN, 20 Spironolactone, 15 Rifampin, 20 Spironolactone/HCTZ, 15 Rimantadine, 20 SSKI, 22 RISPERDAL, 13 STADOL NS, 11 Risperidone, 13 STELAZINE, 13

42 Sucralfate, 17 THYROLAR, 24 SUDAFED, 21 Tiagabine, 11 Sulfacetamide, 23 TIGAN, 17 Sulfacetamide 10%/Prednisolone 0.2%, 23 TIMOPTIC, 23 Sulfacetamide 10%/Prednisolone 0.5%, 23 TINACTIN, 27 Sulfacetamide Lotion, 28 Tioconazole, 27 SULFADIAZINE, 19 Tobramycin, 22 Sulfadiazine, 19 TOBREX, 22 Sulfamethoxazole/Trimethoprim (SMZ/TMP), 19 TOFRANIL, 12 Sulfasalazine, 18 Tolazamide, 24 Sulfisoxazole, 19 Tolbutamide, 24 Sulfonamide Agents, 19 TOLINASE, 24 Sulfonylureas, 24 Tolnaftate, 27 Sulindac, 10 Tolterodine, 26 SULTRIN, 27 TOPAMAX, 12 Sumatriptan, 10 Topical Antibiotic Agents, 27 SUMYCIN, 19 Topical Antifungal Agents, 27 SUPRAX, 19 Topical Anti-Inflammatory Agents, 28 SYMBYAX, 13 Topical Antipruritic and Local Anesthetic Agents, 28 SYMMETREL, 12, 20 Topical Antiviral Agents, 28 SYNALAR, 28 Topical Miscellaneous Anti-Infective Agents, 28 SYNTHROID, 25 TOPICAL/MUCOUS MEMBRANE AGENTS, 27 TOPICORT, 28 —T— TOPICORT LP, 28 Topiramate, 12 Tacrolimus, 28 TOPROL XL, 14 TAGAMET, 18 Tramadol, 11 TAMBOCOR, 14 TRANDATE, 14 TAMIFLU, 20 TRANXENE, 13 TAPAZOLE, 25 Tranylcypromine, 12 TEGRETOL, 11 Trazodone, 13 TEGRETOL XR, 11 TRENTAL, 16 Telmisartan, 14 Triamcinolone, 28 Temazepam, 13 Triamcinolone 0.1% in Orabase, 23 TEMOVATE, 28 Triamcinolone, Nasal, 23 TENEX, 15 Triamcinolone/Nystatin, 27 TENORETIC, 15 Triamterene, 15 TENORMIN, 14 Triamterene 37.5mg/HCTZ 25mg, 15 Terazosin, 15 Triamterene 50mg/HCTZ 25mg, 15 Terbinafine, 19, 27 Triamterene 75mg/HCTZ 50mg, 15 Terbutaline Sulfate, 22 Triazolam, 13 Teriparatide, 25 Tricyclic Antidepressant Agents, 12 TERPIN HYDRATE/CODEINE, 21 TRIDESILON, 28 Terpin Hydrate/Codeine, 21 Triethanolamine, 24 TESSALON, 21 Trifluoperazine, 13 Tetracycline, 19 Trifluridine Ophthalmic Solution, 22 Tetracycline/Bismuth/Metronidazole, 20 Trihexyphenidyl, 12 Tetracyclines, 19 TRILAFON, 13 THEO-DUR, 22 TRILEPTAL, 11 Theophylline, 22 Trimethobenzamide, 17 Theophylline, 80mg/15cc, 22 Trimethoprim, 19, 26 Theophylline, Sustained Release, 22 TRIMOX, 19 Thiamine, 30 TRIMPEX, 19, 26 Thiazide and Related Diuretics, 15 Triple Sulfa Cream, 27 Thioridazine, 13 Triprolidine/Pseudoephedrine/Codeine, 21 Thiothixene, 13 Tropicamide, 23 THORAZINE, 13 TRUSOPT, 23 Thyroid Agents, 24 T-STAT, 27 Thyroid, Desiccated, 25 TUMS, 29

43 TUSSIN PEDIATRIC, 21 VIVELLE DOT, 25 TYLENOL, 11 VOLMAX, 21 TYLENOL/CODEINE, 11 VOLTAREN, 10, 22 TYLOX, 11 VOSOL, 23 VOSOL HC, 23 —U— —W— ULTRAM, 11 UNIPHYL, 22 Warfarin Sodium, 16 URECHOLINE, 26 WELLBUTRIN, 13 Urinary Anti-Infective Agents, 26 WELLBUTRIN SR, 13 Urinary Anti-Spasmodic Agents, 26 WELLBUTRIN XL, 13 URISED, 26 WESTCORT, 28 Ursodiol, 18 —X— —V— XALATAN, 23 Vaginal Antifungal Agents, 27 XANAX, 13 Vaginal Anti-Infective Agents, 28 XYLOCAINE, 23, 28 VAGISTAT-1, 27 Valacyclovir, 20 —Y— VALISONE, 28 VALISONE REDUCED STRENGTH, 28 YODOXIN, 18, 20 VALIUM, 13 Valproic Acid, 11 —Z— Valsartan, 14 Valsartan/HCTZ, 15 ZADITOR OTC, 23 VALTREX, 20 Zanamivir, 20 Vasodilating Agents, 16 ZANTAC (TABLETS ONLY), 18 Vasodilator Antihypertensive Agents, 15 ZAROXOLYN, 15 VASORETIC, 15 ZEPHREX LA, 22 VASOTEC, 14 ZESTORETIC, 15 Venlafaxine, 12 ZESTRIL, 14 Venlafaxine Extended Release, 12 ZIAC, 15 Verapamil, 15 Ziprasidone, 13 Verapamil LA Tablets, 15 ZITHROMAX, 19 Verapamil SR Capsules, 15 ZOCOR, 16 VERELAN, 15 ZOFRAN, 17 VERMOX, 18 Zolmitriptan, 10 VIBRAMYCIN, 19 ZOLOFT, 12 VIBRA-TABS, 19 Zolpidem, 14 VIROPTIC, 22 ZOMIG, 10 VISCOUS XYLOCAINE, 23 ZOMIG ZMT, 10 VISKEN, 14 ZONEGRAN, 11 VISTARIL, 14, 21 Zonisamide, 11 Vitamin Agents, 30 ZOVIRAX OINTMENT, 28 ZOVIRAX ORAL VITAMIN B1, 30 , 20 ZYBAN VITAMIN B12, 30 , 30 ZYLOPRIM VITAMIN B6, 30 , 30 Vitamin B-Complex Agents, 30 ZYPREXA, 13 Vitamin D, 30 ZYPREXA INJECTION, 13 Vitamin K Activity Agents, 30 ZYPREXA RELPREVV, 13 VIVACTIL, 12 ZYPREXA ZYDIS, 13 VIVELLE, 25

44